How To Use CPT Code 81002

CPT 81002 is a code used for non-automated urinalysis without microscopy, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 81002?

CPT 81002 is a medical billing code used for non-automated urinalysis without microscopy. This code is utilized when a lab analyst performs a manual urinalysis using a dipstick or tablet reagent to test for various constituents in a urine sample. The test does not involve the use of automated equipment or microscopic examination.

2. 81002 CPT code description

The official description of CPT code 81002 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, without microscopy.”

3. Procedure

  1. The lab analyst collects a fresh urine specimen.
  2. The analyst inserts a dipstick into the urine specimen and removes it, shaking off excess urine. Alternatively, the analyst may place drops of the urine specimen on a reagent tablet.
  3. After the proper time interval, the lab analyst manually reads the results for one or more ordered analytes using a color chart, usually located on the outside of the container.
  4. The analyst records the results, which may be read semiquantitatively using the plus system (trace, 1+, 2+, 3+, or 4+) or by milligrams per deciliter.
  5. If a tablet reagent is used instead of a dipstick, the analyst places the tablet on an absorbent pad, drops the required number of drops of urine on the tablet, and reads the resultant color at a prescribed interval after adding the urine.
  6. A single unit of CPT 81002 is reported to represent the analysis of any number of the listed constituents.

4. Qualifying circumstances

Healthcare providers may order CPT 81002 services for patients who require urinalysis for various reasons, such as suspected urinary tract infections, kidney function testing, or other conditions and disease states that the chemical analytes and results can reveal and add diagnostic information for. The lab analyst performing the test must be qualified and trained in manual urinalysis techniques.

5. When to use CPT code 81002

CPT code 81002 should be used when a non-automated urinalysis without microscopy is performed to test for any number of the listed constituents in a urine sample. This code is appropriate for manual urinalysis procedures that do not involve the use of automated equipment or microscopic examination.

6. Documentation requirements

To support a claim for CPT 81002, the following information should be documented:

  • Patient’s name and date of birth
  • Date and time of urine specimen collection
  • Indication for the urinalysis (e.g., suspected urinary tract infection, kidney function testing, etc.)
  • Specific constituents tested for in the urinalysis
  • Results of the urinalysis, including any abnormal findings
  • Name and credentials of the lab analyst performing the test

7. Billing guidelines

When billing for CPT code 81002, it is essential to ensure that the procedure is medically necessary and appropriately documented. Additionally, be aware of any payer-specific guidelines or requirements for billing this code. If the urinalysis is performed using automated equipment or includes microscopic examination, different CPT codes should be used, such as 81003 for automated urinalysis without microscopy or 81001 for urinalysis with microscopy.

8. Historical information

CPT 81002 was added to the Current Procedural Terminology system on January 1, 1990. There have been no significant updates to this code since its addition.

9. Similar codes to CPT 81002

Five similar codes to CPT 81002 and how they differ are:

  • CPT 81001: Includes both the chemical analysis and microscopic examination of the urine sample.
  • CPT 81003: Involves the use of automated equipment for the chemical analysis without microscopy.
  • CPT 81005: A basic urinalysis that tests for fewer constituents than CPT 81002.
  • CPT 81007: Focuses specifically on the microscopic examination of the urine sample for urobilinogen.
  • CPT 81015: Involves only the microscopic examination of the urine sample without chemical analysis.

10. Examples

  1. A patient presents with symptoms of a urinary tract infection, and the healthcare provider orders a non-automated urinalysis without microscopy to test for leukocytes and nitrite.
  2. A patient with diabetes undergoes a manual urinalysis to monitor glucose and ketone levels in their urine.
  3. A patient with a history of kidney stones has a non-automated urinalysis performed to assess specific gravity and pH levels in their urine.
  4. A patient with liver disease undergoes a manual urinalysis to test for bilirubin and urobilinogen in their urine.
  5. A healthcare provider orders a non-automated urinalysis without microscopy to test for protein in a patient’s urine as part of a routine health screening.
  6. A patient with anemia has a manual urinalysis performed to assess hemoglobin levels in their urine.
  7. A patient with suspected kidney dysfunction undergoes a non-automated urinalysis without microscopy to test for specific gravity, pH, and protein in their urine.
  8. A healthcare provider orders a manual urinalysis to monitor a patient’s response to medication by testing for glucose and ketone levels in their urine.
  9. A patient with a history of urinary tract infections has a non-automated urinalysis performed to test for leukocytes, nitrite, and pH levels in their urine as part of a follow-up appointment.
  10. A patient undergoing a pre-employment health screening has a manual urinalysis performed to test for any abnormalities in their urine, including glucose, protein, and specific gravity levels.

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