How To Use CPT Code 81000

CPT 81000 describes the procedure for performing a urinalysis by dip stick or tablet reagent for various constituents such as bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 81000?

CPT 81000 is used to describe the procedure for performing a urinalysis by dip stick or tablet reagent. This test is used to analyze various constituents in the urine, including bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen. The results of the urinalysis can provide valuable information about a patient’s kidney function, urinary tract infections, and other conditions or diseases.

2. Official Description

The official description of CPT code 81000 is: ‘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.’

3. Procedure

1. The lab analyst collects a freshly collected urine specimen from the patient.
2. The lab analyst inserts a dip stick into the urine specimen or places drops of the urine on a reagent tablet.
3. After the appropriate time interval, the lab analyst manually reads the results for each ordered analyte using a color chart or by measuring milligrams per deciliter.
4. The lab analyst performs a microscopic examination on the urine sediment after centrifuging the specimen.
5. The lab analyst examines the sediment under the microscope using both low and high power and reports the results, including cellular elements, casts, crystals, and other urinary elements.

4. Qualifying circumstances

CPT 81000 can be performed by qualified lab analysts who are trained to perform urinalysis. The test can be ordered by clinicians for various reasons, including the evaluation of kidney function, detection of urinary tract infections, and assessment of specific constituents in the urine. The test can be performed on patients of all ages and does not have specific qualifying circumstances.

5. When to use CPT code 81000

CPT code 81000 should be used when performing a non-automated urinalysis using dip stick or tablet reagent methods. This code is appropriate when analyzing any number of the listed constituents, such as bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen. It is important to note that CPT code 81000 is for non-automated urinalysis, while CPT code 81001 is used for automated urinalysis.

6. Documentation requirements

To support a claim for CPT code 81000, the following documentation is required:

• Documentation of the specific constituents analyzed in the urinalysis
• Date and time of the urinalysis procedure
• Results of the dip stick or tablet reagent analysis, including any semiquantitative measurements
• Results of the microscopic examination, including cellular elements, casts, crystals, and other urinary elements
• Signature of the lab analyst performing the urinalysis

7. Billing guidelines

When billing for CPT code 81000, ensure that the procedure is performed by a qualified lab analyst using non-automated methods. It is important to follow the specific guidelines for reporting CPT code 81000 and to accurately document the results of the urinalysis. CPT code 81000 should not be reported with CPT codes 81001 to 81099, as these codes represent different procedures or automated urinalysis.

8. Historical information

CPT code 81000 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A lab analyst performing a urinalysis to detect the presence of glucose and protein in a patient’s urine.
2. A clinician ordering a urinalysis to evaluate a patient’s kidney function and assess the specific gravity and pH of their urine.
3. A lab analyst performing a urinalysis to detect the presence of leukocytes and nitrite, indicating a possible urinary tract infection.
4. A clinician ordering a urinalysis to monitor a patient’s ketone levels and assess their diabetes management.
5. A lab analyst performing a urinalysis to detect the presence of bilirubin and urobilinogen, which can indicate liver or gallbladder dysfunction.
6. A clinician ordering a urinalysis to assess a patient’s hemoglobin levels and screen for possible blood in the urine.
7. A lab analyst performing a urinalysis to detect the presence of crystals and casts, which can provide diagnostic information for certain kidney disorders.
8. A clinician ordering a urinalysis to evaluate a patient’s urinary pH and assess their risk for kidney stone formation.
9. A lab analyst performing a urinalysis to detect the presence of specific cellular elements, such as red blood cells or white blood cells, indicating a possible urinary tract infection or kidney disease.
10. A clinician ordering a urinalysis to assess a patient’s specific gravity and protein levels, which can provide information about their hydration status and kidney function.