(Reproduced by permission from Medicare Focus, July, 1998, pp. 13 - 17.)

Medicare Part A - Revised
Local Medical Review Policy
Urinalysis

Policy Number: A98-26

Description

Urinalysis is the physical, chemical or microscopic analysis or examination of urine. Medicare provides coverage for services that are medically reasonable and necessary. Medicare cannot provide coverage for urinalysis performed without relationship to the evaluation or treatment of a symptom, sign, complaint, illness or injury.

Type of Bill: 12X, 13X, 14X, 21X, 22X, 23X, 71X, 72X, 73X

Revenue Codes: 30X, 31X

Indications and Limitations

In order for Medicare coverage to be provided for urinalysis, the patient must have signs or symptoms of a kidney/urinary tract disorder or a condition or a condition that is known to affect the kidney/urinary tract. A urinalysis will be considered medically necessary if any of the following circumstances exist:

  1. The patient has symptoms suggestive of possible kidney/urinary tract disorder, e.g., dysuria, frequency, hesitancy, flank pain, nocturia, urgency, pelvic pain, abdominal pain, etc.
  2. The patient exhibits signs of kidney/urinary tract disorder such as hematuria, discoloration of urine, malodorous urine, edema.
  3. The patient has been recently treated or is under treatment for a urinary tract disorder and follow-up urinalysis is necessary to evaluate the patient. (Submit the ICD-9 code for the treated condition.)
  4. The patient has a condition known to effect the kidneys or urinary tract, e.g., hypertension, diabetes mellitus, known renal disease, collagen vascular disease, etc., and urinalysis is necessary to evaluate the patient.
  5. The patient is undergoing treatment with a medication known to potentially adversely affect the kidneys, e.g. gold therapy.
  6. The patient has sustained trauma suggestive of possible kidney/urinary tract injury.
  7. The patient has unexplained fever.
  8. The patient has symptoms suggestive of impotency of an organic origin (ICD-9-CM code 607.84, 608.9) and is seen for a new patient visit or consultation (CPT 99201-99205, 99241-99245).
HCPCS Codes

81000

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
81001.....automated, with microscopy
81002.....non-automated, without microscopy
81003.....automated, without microscopy
81005Urinalysis; qualitative or semiquantitative, except immunoassays
81015.....microscopy only


Diagnosis Codes for Coverage

One of the following covered ICD-9-CM diagnosis codes must be linked to the appropriate procedure.

Diagnosis Definition

ICD-9-CM Code Description
V10.46
V10.51
V10.52
V10.53
Persons with Potential Health Hazards Related to Personal and Family History
(Note: V10.53 added per Medicare Focus December, 2001
V42.0 Persons with a Condition Influencing Their Health Status
V58.69 Person Encountering Health Services for Specific Procedures and Aftercare
V67.51 Persons Encountering Health Services in Other Circumstances
038.0 - 038.9 Other Bacterial Diseases
185
188.0 - 189.9
Malignant Neoplasm of Genitourinary Organs
222.2 Benign Neoplasms
236.7 Neoplasm of Uncertain Behavior of Bladder
(Updated in Medicare Focus, May 1999, pg. 12)
239.4
239.5
Disorders of Thyroid Gland
250.00 - 250.43 Diseases of Other Endocrine Glands
271.4
276.5
Other Metabolic and Immunity Disorders
344.61 Other Disorders of the Central Nervous System
401.0 - 405.99 Hypertensive Disease
(Updated in Medicare Focus, October, 2001)
428.0 Other Forms of Heart Disease
446.0 - 446.5
447.6
Diseases of Arteries, Arterioles, and Capillaries
571.2 - 571.6 Other Diseases of the Digestive System
580.0 - 602.8 Nephritis, Nephrotic Syndrome, and Nephrosis
604.0 - 604.99 Diseases of Male Genital Organs
618.0
625.6
Other disorders of Female Genital Tract
634.00 - 638.9
639.3 - 639.5
639.8
Other Pregnancy with Abortive Outcome
642.00 - 642.94
644.00 - 644.21
646.20
646.50 - 646.60
Complications Mainly Related to Pregnancy
669.30 - 669.34 Complications Occurring Mainly in the Course of Labor and Delivery
710.0 -710.9
711.00 - 711.09
714.0
Arthropathies and Related Disorders
725 Rheumatism, Excluding the Back
753.10 - 753.19 Congenital Anomalies
780.6
782.3
783.21 Revised per Medicare Focus December, 2000
788.0 - 789.09
Symptoms
790.93
791.0 - 791.9
Nonspecific Abnormal Findings
866.0 - 866.13
867.0 - 867.1
867.2 - 867.3
867.6
Internal Injury of Thorax, Abdomen and Pelvis
959.1 Certain Traumatic Complications and Unspecified Injuries
982.2
985.0
Toxic Effects of Substances Chiefly Non-Medicine As To Source

One of the following covered ICD-9-CM diagnosis codes must be linked to CPT codes 99201-99205, 99241-99245:

Diagnosis Definition

ICD-9-CM Code Description
607.84
608.9
Disease of Male Genital Organs

Category: Pathology and Laboratory

Organ System

Genitourinary System

HCFA National Policy:

Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary, i.e., reasonable and necessary are those tests used in the diagnostic and management of illness or injury or improve the function of a malformed body part.

Title XVIII of the Social Security Act, section 1862(a)(7). This section excludes routine physical examinations.

Reasons for Denial

Tests performed during pre-operative examinations, annual physical examinations or other routine screening situations without signs, symptoms or illness will result in the claim being denied as a non-covered benefit. These ICD-9-Code(s) are (Codes that are never covered): V70.0 - V70.9.

Non-Covered Diagnosis Codes

Any that are not listed as covered diagnosis codes in the "Covered ICD-9-CM Codes" section in this policy.

Sources of Information

John Bernard Henry, M.D., Clinical Diagnosis and Management by Laboratory Methods, 1996
Medicare Intermediary Manual sections 3168 & 3133.5
Medicare Part B Local Medical Review Policy

Documentation Required

Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.

Documentation including progress notes and laboratory reports must be maintained in the patient's medical record indicating the medical necessity of urinalyses covered by Medicare.

If documentation is requested for review, submit the following:


Comments

This policy is a replacement of and supersedes all previous policies on urinalysis. This policy will be utilized in conducting focused medical review and postpayment audits.

Approval


This policy is being adapted from the Carrier policy. It does not represent the sole opinion of the Intermediary/Medical Director. This policy was developed in consultation with the medical community via the Carrier Advisory Committee.

Start Date of Comment Period: March 10, 1998
Start Date of Notice Period:

July 1, 1998
Effective Date: August 1, 1998