How To Use CPT Code 81015

CPT 81015 describes the procedure for a microscopic urinalysis only. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 81015?

CPT 81015 can be used to describe the procedure for a microscopic urinalysis only. This code is used when a lab analyst examines a urine specimen directly under a microscope or by using the sediment from a centrifuged urine specimen to report cellular elements and other objects present in the urine.

2. Official Description

The official description of CPT code 81015 is: ‘Urinalysis; microscopic only.’

3. Procedure

1. The lab analyst performs the microscopic urinalysis on a random or early morning urine specimen, preferably a clean catch sample.
2. The urine specimen is centrifuged to concentrate the sediment.
3. The lab analyst examines the sediment under the microscope, using both low and high power, to identify and report cellular elements, such as white blood cells, red blood cells, epithelial cells, casts, and other objects present in the urine.
4. In certain cases, the lab analyst may examine the urine specimen directly without concentrating it.

4. Qualifying circumstances

CPT 81015 is typically ordered when the clinician wants to focus solely on the cellular elements seen under the microscope or when rechecking a previous urinalysis for a specific cellular element. It is important to note that this code should only be used for a microscopic urinalysis and not in combination with a dipstick chemical urinalysis test.

5. When to use CPT code 81015

CPT code 81015 should be used when the order is specifically for a microscopic urinalysis only. It should not be used when the lab adds a microscopic urinalysis onto a dipstick chemical urinalysis test, as that would require a different code combination.

6. Documentation requirements

To support a claim for CPT 81015, the lab analyst must document the following information:

• Type of urine specimen (random, early morning, clean catch)
• Method used to prepare the specimen (centrifugation or direct examination)
• Microscopic findings, including cellular elements and other objects present in the urine

7. Billing guidelines

When billing for CPT 81015, ensure that the procedure performed is a microscopic urinalysis only. Do not report this code if a dipstick test for chemical constituents is also ordered. It is important to review the requirements for which providers are eligible to perform the microscopic examination required for this code.

8. Historical information

CPT 81015 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A lab analyst performs a microscopic urinalysis on a clean catch urine sample and reports the presence of red blood cells and epithelial cells.
2. A urine specimen is centrifuged, and the lab analyst examines the sediment under the microscope, identifying white blood cells and casts.
3. A lab analyst directly examines a urine specimen without concentrating it, reporting the presence of crystals and parasites.
4. A microscopic urinalysis is performed to recheck a previous urinalysis for the presence of red blood cells.
5. A lab analyst examines a urine specimen under the microscope, identifying epithelial cells and other objects present in the urine.