Urology Coding Alert

Plus: Ensure the diagnosis supports medical necessity.

Reporting urine cultures is common in many physician offices, but especially for urology. Before submitting your claim, be sure to dig into the details to ensure you’re making the right choice.

Starting Point: Know What the Primary Codes Represent

When you prepare to report a urine culture, you have several lab code choices:

• 87086 (Culture, bacterial; quantitative colony count, urine) represents the initial identification of bacterial organisms in a urine sample. Turn to 87086 when your physician wants a urine culture colony count to determine the approximate number of bacteria present per milliliter of urine.
• 87088 (… with isolation and presumptive identification of each isolate, urine) describes the use of a commercial kit that uses manufacturer-defined media for isolation, presumptive identification, and quantification of morphotypes present. Your physician should only order the test covered by 87088 after 87086 has been performed on the urine specimen and has positively identified that a bacterial organism is present.
• Codes 87184 (Susceptibility studies, antimicrobial agent; disk method, per plate [12 or fewer agents]) and 87186 (…microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each multi-antimi­crobial, per plate]) represent sensitivity (or susceptibility) studies. If a urine culture is positive for bacterial growth, the urologist might order one of these tests to determine the antibiotic sensitivity of the infecting microorganisms. Codes 87184 and 87186 are not urology-specific, however; they are also used to test for (and report) isolates from other sources.

“In years past, you were unable to report 87086 and 87088 for the same encounter,” says Chandra L. Hines, business office manager for NC Urological Associates Inc. in Raleigh, N.C. CMS reversed that bundling, so you are allowed to report 87086 and 87088 during the same encounter.

Here’s why: Most lab culture codes include both the isolation and presumptive organism identification. Although urine culture code 87086 is unique, another code is also available to report presumptive identification (87081, Culture, presumptive, pathogenic organisms, screening only) in addition to 87086 for the isolation.

Don’t Forget About 87081

Your most common choices for urine screenings are 87086 and 87088. But don’t miss 87081 as mentioned above, which is a more basic culture test. Code 87081 is a urine screening study to identify the presence of bacteriuria before formal studies 87086, 87088, and 87184 points out Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook.

Code 87081 can be used in any office registered with a minimal CLIA certificate. Offices with a higher CLIA certificate will often start with 87086, and if the test is positive, expand testing to 87088 and 87184.

Payers usually reimburse these latter three studies at a slightly higher rate than 87081, reflecting their increased laboratory complexity and the extra work involved. The following rates are based on the 2018 Clinical Diagnostic Laboratory Fee Schedule:

• 87081 – $8.18
• 87086 – $9.96
• 87088 – $9.99
• 87184 – $8.51

Follow the Correct Testing Order

You should only report 87088 after you’ve already reported 87086, and the urologist has positively identified significant bacterial growth in the urine.

Document it: Once a culture is planted, it takes two days to get results. After you record the positive result in the patient’s record, print a hard copy to include with the claim. Before billing both codes, verify that you have documentation of the presumptive identification of an organism. Then submit the claim with both 87086 and 87088.

You do not need to append any modifiers (such as 59, Distinct procedural service) to receive payment for both codes. You will simply get full reimbursement for both codes, provided you have clear documentation.

Example: A urologist sees a patient with burning on urination, frequency, and urgency of urination. A urinalysis reveals many white blood cells and microscopic hematuria. The urologist suspects a UTI and orders a urine culture and quantitative colony count (87086). This culture indicates a large number of bacteria (over 100,000 organisms per ml). Having confirmed a significant UTI and wishing to know the organism(s) involved in causing the infection, the urologist then orders an identification of the bacteria (87088).

Connect the Correct Diagnosis

CMS regulations specify certain indications for urine cultures or studies. The urologist’s documentation needs to show at least one of these indications in order to support medical necessity. Examples of these indicators are:

• The patient has abnormal urinalysis results that suggest a UTI, such as hematuria (R31.9) or pyuria (N39.0).
• The patient has clinical symptoms, such as urinary frequency (R35.0) and burning (R30.0, Dysuria), which indicate a possible acute lower or upper urinary tract infection.
• The patient presents with a fever of unknown origin (R50.9) or suspected urosepsis (N39.0).

The urologist orders the urine culture as a means of detecting occult infection in a renal transplant recipient who is on immunosuppressive therapy (Z94.89).