Wiki Urinalysis

[eandmcoder]

What documentation is required for urinalysis CPT codes (8100X) that accompany an E&M code (ex: 99214, 81002)? In this case there is a urinalysis data printout attached to the note in the chart, but no textual documentation. Is the latter required?

Generally, a nurse does the urinalysis. Sometimes the provider looks at it and sometimes no. Is there any difference in billing based on whether the provider looked at the data or not--such as use of modifier 26 or TC?

Thanks