Question:

Could you provide billing guideline for microscopic examination of a urine sample without macroscopic observation?

Answer:

Microscopic examination of a urine sample without macroscopic observation is documented with 81015— urinalysis; microscopic only. CMS considers billing for 81015 concurrently with 81002 or 81003 as unbundling, and billing for 81015 concurrently with 81000 or 81001 is considered double billing. This is a common occurrence at facilities with decentralized point-of-care testing.

Allowing emergency department, outpatient surgery, or hospital-based clinics (that use the same provider number) to perform the macroscopic urinalysis, then reflex the sample to the main lab to perform the microscopic test only, when indicated by abnormal results on the dipstick, can result in compliance issues.


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This question was answered in an edition of our Laboratory Compliance Manager. For more hot topics relating to laboratory services, please view our store, or call us at 1.800.252.1578 ext. 2.

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CPT is a registered trademark of the American Medical Association.