Pediatric Coding Alert

Question: Which modifier would allow us to report urinalysis code 81003 along with an E/M code?

New Jersey Subscriber

Answer: Unfortunately, many payers won’t reimburse you for both services. For instance, Horizon Blue Cross Blue Shield of NJ has a policy stating, “Urinalysis procedures (81002 or 81003) when billed in conjunction with any E/M service will not be separately reimbursed when a modifier 25 is appended to the E/M service or a modifier 59 is appended to the urinalysis procedure, on the same day, for the same member, by the same provider, on the same or different claims.”

If you report both the urinalysis and the E/M visit, your payer will only reimburse you for the E/M and will completely disregard the E/M, costing you about $3.00 in lost reimbursement for each urinalysis claim.

For payers that do reimburse for both, you’ll most likely append modifier 25 (Significant, separately identifiable evaluation and management [E/M] service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to reflect that the evaluation was separately identifiable from the lab test.