Pediatric Coding Alert

Tip 1: Understand the Documentation

Before you can bill for a urinalysis test, you’ll need documentation from your pediatrician. “This means you’ll need a signed order for the test, and you will need proof that your practice conducted it,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

“In addition, the order should specify whether the test will use microscopy, because if it doesn’t, an auditor will downgrade the service to a service that does not involve microscopy, which are simpler and less expensive tests. Your documentation does not need to specify if the urinalysis is automated, as this is just the method of testing. But you will have to know which method your pediatrician has ordered,” Falbo notes.

To do that, you will need to take our second tip.

Tip 2: Understand the Tests

Most pediatric practices have the ability to conduct one or more of the following urinalysis tests:

• 81000 (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, with microscopy)
• 81001 (... automated, with microscopy)
• 81002 (... non-automated, without microscopy)
• 81003 (...automated, without microscopy)

Choosing the proper code from these four is relatively easy providing you know the different processes described in the code descriptors:

Non-automated tests involve comparing the color changes on a test strip after it has been placed in the urine sample to a color chart provided by the test manufacturer. This can also be done by placing a reagent tablet in the sample, which changes the color of the urine (codes 81000 and 81002).

Automated tests involve a machine that analyzes the test strip automatically (codes 81001 and 81003).

Microscopy tests involve viewing elements in the urine sample such as bacteria or crystals using a microscope (codes 81000 and 81001).

So, if your tester views a test strip manually without using a microscope for further analysis, you would select urinalysis code 81002.

Tip 3: Understand QW Modifier Use

One source of confusion surrounding 81000–81003 involves whether or not you should append modifier QW (CLIA waived test). Two of the tests ¾ 81002 and 81003, which are the tests that do not involve microscopy ¾  appear on the list of CLIA-waived tests, which you can find at www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf.

But a closer look at the list shows that only 81003 takes the QW modifier. And even then, not all 81003 tests will take the modifier. Only the ones listed at www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/analyteswaived.cfm will take it, so if you are unsure, search the list for the particular test your pediatrician is using.

Coding Alert 1: To perform CLIA-waived tests, your office must have a Certificate of CLIA waiver. If your practice does not already have one, you can view the process involved in obtaining one by going to www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/HowObtainCertificateofWaiver.pdf.

Tip 4: Understand Separate Reporting for Urinalysis Tests

The good news here is that this tip is easy to remember. That’s because no National Correct Coding Initiative (NCCI) edit exists for 81000-81003 when the tests are Column 2, or component, codes for office/outpatient evaluation and management (E/M) services 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/ established patient …), and no CPT^® guidelines prohibit billing the services separately in the pediatric setting.

The exception to the rule: “Some payers will consider codes 81001 and 81002 as included in the global period for antepartum or global ob-gyn service when submitted with an ob-gyn diagnosis code in the office setting,” says Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia.

“For non ob-gyn patients, however, the urinalysis is usually separately reported with an E/M, but some payers may require a modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] appended to the E/M,” Falbo adds.

In cases where payers deny 81000-81003 when bundled into an office/outpatient E/M, you can also try appending modifier 59 (Distinct procedural service) to the 81000-81003 codes to see if that overrides the edit in question.