Pathology/Lab Coding Alert

Question: When we perform a urinalysis for bilirubin, hemoglobin, leukocytes, pH, protein and semiquantitative creatinine to look for kidney damage, how should we code the service?


Texas Subscriber


Answer: Selecting the proper urinalysis code depends on how the lab performs the test. You didn't mention microscopy, so assuming that you did not perform a microscopic examination of the urine specimen, you can choose from the following codes depending on your instrumentation and methodology:

- 81002--Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy

- 81003 --...automated, without microscopy Any or all: Because the code definition says -any number of these constituents,- you should select one of these codes for the testing you mentioned, even though the lab did not analyze for all of the listed constituents in codes 81002 and 81003.

But you-ll also notice that -creatinine- is not among the items listed for testing in 81002 or 81003. If the lab additionally performs a semiquantitative creatinine on the urine specimen, you should also report 82570 (Creatinine; other source).

Don't forget QW: If your lab operates as a waived-status lab under Clinical Laboratory Improvement Amendments (CLIA), you should use modifier QW (CLIA-waived test) with codes 81003 and 82570. However, 81002 is one of the few tests that does not require modifier QW for CLIA-waived labs.