How To Use CPT Code 81003

CPT 81003 is a code used for automated urinalysis without microscopy, covering a variety of constituents. This article will discuss the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 81003.

1. What is CPT 81003?

CPT 81003 is a medical billing code used for automated urinalysis without microscopy. This code covers the analysis of various constituents in a urine sample, such as bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen. The test is performed using a dipstick or tablet reagent and an automated reader, providing valuable diagnostic information for clinicians.

2. 81003 CPT code description

The official description of CPT code 81003 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; automated, without microscopy.”

3. Procedure

1. The lab analyst collects a fresh urine specimen.
2. The analyst inserts a dipstick or tablet reagent into the urine sample.
3. The dipstick or tablet reagent is removed and excess urine is shaken off.
4. The dipstick or tablet reagent is placed onto an automated reader.
5. The reader automatically analyzes and records the various constituents in the urine sample.
6. The results are reported semiquantitatively or quantitatively, depending on the constituent.

4. Qualifying circumstances

Patients eligible to receive CPT 81003 services are those who require urinalysis for diagnostic purposes. Clinicians may order this test for various reasons, such as evaluating kidney function, detecting urinary tract infections, or assessing other conditions and disease states. The code applies when any one or more of the ten listed constituents are ordered for analysis using an automated technique.

5. When to use CPT code 81003

It is appropriate to bill CPT 81003 when a clinician orders an automated urinalysis without microscopy for any of the ten listed constituents. This code can be used for a single constituent or multiple constituents, as long as the test is performed using an automated technique.

6. Documentation requirements

To support a claim for CPT 81003, the following information should be documented:

• Clinician’s order for the urinalysis, specifying the constituents to be analyzed.
• Details of the urine specimen collection, including date and time.
• Results of the automated urinalysis, including the values for each constituent analyzed.
• Any relevant clinical notes or observations related to the urinalysis.

7. Billing guidelines

When billing for CPT 81003, it is essential to ensure that the test was performed using an automated technique and without microscopy. If the test includes microscopy, the appropriate code would be CPT 81001. Additionally, only a single unit of CPT 81003 should be reported, regardless of the number of constituents analyzed. It is crucial to follow all applicable billing rules and guidelines to ensure accurate reimbursement for services provided.

8. Historical information

CPT 81003 was added to the Current Procedural Terminology system on January 1, 1993. There have been no updates to the code since its addition.

9. Similar codes to CPT 81003

Five similar codes to CPT 81003 and how they differ are:

• CPT 81001: Includes automated urinalysis with microscopy.
• CPT 81002: Covers non-automated urinalysis without microscopy.
• CPT 81000: Involves manual urinalysis with microscopy.
• CPT 81007: Pertains to automated urinalysis for urobilinogen only.
• CPT 81015: Refers to manual urinalysis for sediment concentration only.

10. Examples

1. A patient presents with symptoms of a urinary tract infection, and the clinician orders an automated urinalysis for leukocytes, nitrite, and pH.
2. A patient with diabetes requires regular monitoring of glucose levels in their urine using an automated urinalysis.
3. A patient with a history of kidney stones undergoes an automated urinalysis to assess specific gravity and pH levels in their urine.
4. A patient with liver disease has an automated urinalysis ordered to evaluate bilirubin and urobilinogen levels in their urine.
5. A patient with suspected hematuria undergoes an automated urinalysis to detect the presence of hemoglobin in their urine.
6. A patient with a suspected metabolic disorder has an automated urinalysis ordered to analyze ketone levels in their urine.
7. A patient with proteinuria undergoes an automated urinalysis to monitor protein levels in their urine.
8. A patient with a suspected renal tubular acidosis has an automated urinalysis ordered to assess pH levels in their urine.
9. A patient with a history of nephrotic syndrome undergoes an automated urinalysis to evaluate specific gravity and protein levels in their urine.
10. A patient with suspected porphyria has an automated urinalysis ordered to analyze urobilinogen levels in their urine.