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A urinalysis is a diagnostic procedure that involves the examination of urine to assess various health conditions. This specific test, identified by CPT® Code 81000, utilizes dip stick or tablet reagent methods to analyze multiple constituents in the urine, including bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen. The procedure is categorized as non-automated and includes microscopy for a more detailed examination of the urine sample. The dip stick method employs a paper or plastic stick with color strips that react to the presence of specific substances in the urine. When the stick is immersed in the urine sample, the color changes on the strips are compared to a color chart to determine the presence or concentration of the tested agents. Alternatively, the tablet reagent method involves placing a few drops of urine on an absorbent mat, followed by the addition of a reagent tablet and distilled water, allowing for a color change that indicates the presence of certain substances. The analysis of these constituents can provide critical insights into various medical conditions that may not present immediate symptoms, such as diabetes mellitus, kidney disease, or urinary tract infections. For instance, the detection of bilirubin in urine can indicate liver dysfunction, while the presence of glucose may suggest diabetes. Hemoglobin detection can reveal issues such as hematuria or myoglobinuria, and the presence of ketones may indicate diabetic ketoacidosis or starvation. Additionally, the test assesses the pH level of urine, protein levels, and specific gravity, which can reflect kidney function and overall metabolic health. Following the initial dip stick or tablet testing, the urine sample is subjected to microscopic examination, where the sediment is analyzed for various cellular components, including crystals, casts, and blood cells. This comprehensive approach allows healthcare providers to diagnose and monitor a range of conditions effectively.
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The urinalysis performed using CPT® Code 81000 is indicated for the evaluation of various health conditions. The following are the specific indications for this procedure:
The procedure for conducting a urinalysis using CPT® Code 81000 involves several key steps, which are detailed below:
After the urinalysis is completed, the results are interpreted by a qualified healthcare professional. The findings from the dip stick and microscopic examination can provide valuable information regarding the patient's health status. Depending on the results, further diagnostic testing or treatment may be recommended. It is important for healthcare providers to document the findings accurately and communicate any significant results to the patient for appropriate follow-up care. Additionally, the healthcare provider may discuss lifestyle modifications or further evaluations based on the urinalysis results.
| Short Descr | URINALYSIS NONAUTO W/SCOPE | Medium Descr | URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY | Long Descr | 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 | Status Code | Statutory Exclusion (from MPFS, may be paid under other methodologies) | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 9 - Not Applicable | Multiple Procedures (51) | 9 - Concept does not apply. | Bilateral Surgery (50) | 9 - Concept does not apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 9 - Concept does not apply. | Co-Surgeons (62) | 9 - Concept does not apply. | Team Surgery (66) | 9 - Concept does not apply. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | CLIA Waived (QW) | No | APC Status Indicator | Conditionally packaged laboratory tests | Type of Service (TOS) | 5 - Diagnostic Laboratory | Berenson-Eggers TOS (BETOS) | T1C - Lab tests - urinalysis | MUE | 2 | CCS Clinical Classification | 206 - Microscopic examination (bacterial smear, culture, toxicology) |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GA | Waiver of liability statement issued as required by payer policy, individual case | GW | Service not related to the hospice patient's terminal condition | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Q4 | Service for ordering/referring physician qualifies as a service exemption | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GC | This service has been performed in part by a resident under the direction of a teaching physician | 90 | Reference (outside) laboratory: when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number. | QW | Clia waived test | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | JZ | Zero drug amount discarded/not administered to any patient | 91 | Repeat clinical diagnostic laboratory test: in the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. note: this modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. this modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). this modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | 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: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 26 | Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. | 33 | Preventive services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a us preventive services task force a or b rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. for separately reported services specifically identified as preventive, the modifier should not be used. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 93 | Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system : synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AY | Item or service furnished to an esrd patient that is not for the treatment of esrd | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CG | Policy criteria applied | CR | Catastrophe/disaster related | CS | Cost-sharing waived for specified covid-19 testing-related services that result in and order for or administration of a covid-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in rural health clinics and federally qualified health centers during the covid-19 public health emergency | FP | Service provided as part of family planning program | GE | This service has been performed by a resident without the presence of a teaching physician under the primary care exception | GT | Via interactive audio and video telecommunication systems | GZ | Item or service expected to be denied as not reasonable and necessary | LT | Left side (used to identify procedures performed on the left side of the body) | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Q3 | Live kidney donor surgery and related services | Q5 | Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | SA | Nurse practitioner rendering service in collaboration with a physician | U6 | Medicaid level of care 6, as defined by each state | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2011-01-01 | Changed | Short description changed. |
| Pre-1990 | Added | Code added. |
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