(Reproduced by permission from Medicare Focus, June, 1998, pp. 9 - 13.)

Medicare Part A
Local Medical Review Policy
Culture, Bacterial, Urine

Policy Number: A96-04 (Revised - Republished for Diagnosis List Verification)

Description

A urine culture colony count (CPT code 87086) is performed to determine if clinically significant bacteriuria is present. Culture by commercial kit (CPT code 87087) utilizes a dipstick medium which is incubated for 24-48 hours yielding either a negative or positive result without identification of bacteria or quantitation. Bacterial identification of colonies (CPT code 87088) is performed to aid in the proper selection of antibiotics with a urinary tract infection is identified.

Type of Bill: 13X, 14X, 22X, 23X, 71X, 74X, 75X

Revenue Codes: 300-319

Indications and Limitations

Urine cultures are covered by Medicare for patients exhibiting signs and symptoms of upper or lower urinary tract infections (UTI). Culture may also be indicated in asymptomatic patients when abnormalities are found on urinalysis which suggest the presence of infection, or to evaluate the response of patients with chronic UTI who are on long-term antibiotics. Acute lower UTI generally presents with symptoms such as urgency, frequency, nocturia, dysuria, or hematuria. These symptoms may be absent in kidney infections, which may present as fever and chills with or without pain in the costovertebral angle.

The presence of organisms on Gram's stain of an unspun urine, or significant bacteriuria on culture are indicative of UTI. Colony counts of 100,000/ml or more considered clinically significant if the patient is not on antibiotics. Lower counts are usually due to contaminants.

A urine culture is not always needed for otherwise healthy female patients presenting with acute onset symptoms and abnormal findings on urinalysis. These patients usually respond well to empiric therapy. UTI in male patients generally require culture with sensitivity studies if the culture is positive. Patients with chronic indwelling catheters are not usually candidates for urine cultures unless either of the following conditions exist:

  1. A culture is done in anticipation of discontinuing the catheter.
  2. The patient becomes symptomatic and treatment is contemplated.
Follow-up cultures after therapy is completed are not routinely necessary in patients with uncomplicated acute cystitis who respond to therapy. Indications for follow-up cultures include patients with complicated infections (i.e., those with urinary tract anomalies, foreign bodies, stones); those at high risk for relapse (e.g., resistant organisms, or patients with recurrent infections who are on long-term antibiotics).

HCPCS Codes

87086Culture, bacterial, urine; quantitative, colony count
87087.....commercial kit
87088.....identification, in addition to quantitative or commercial kit

ICD-9 Codes That Support Medical Necessity

ICD-9-CM Code Description
038.0 - 038.9 Other Bacterial Diseases
580.0 - 589.9 Nephritis, Nephrotic Syndrome, and Nephrosis
590.0 - 599.9 Other Diseases of Urinary System
600.0 - 608.9 Diseases of Male Genital Organs
619.0 - 619.9 Other Disorders of Female Genital Tract
780.6
788.0 - 788.9
Symptoms
790.7
791.0
791.7
791.9
Nonspecific Abnormal Findings
V44.50-V44.59 Revised per Medicare Focus March, 2002
V44.6
Persons with a Condition Influencing Their Health Status
V55.5
V55.6
Persons Encountering Health Services for Specific Procedures and Aftercare



HCPCS Section and Benefit Category: Pathology and Laboratory

HCFA National Coverage 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 reasonable and medically necessary, i.e., reasonable and necessary are those tests used in the diagnosis and management of illness or injury or to 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.

Reason for Denial

Urine cultures performed for routine screening purposes will be denied as not reasonable and necessary. Routine screening and prophylactic testing are not allowed for payment purposes in the Medicare program. Thsee are non-covered services which means that while such use may represent good medical practice, this type of testing cannont be reimbursed by Medicare. Only those services which directly relate to disease, injury or malfunctioning body parts are covered by Medicare. Excessive frequency of testing will be denied as not medically necessary.

It is not reasonable or necessary to do identification of organisms when the colony count is less than 100,000/ml unless the patient is on antibiotics.

Non-Covered ICD-9 Diagnosis Codes

Any diagnosis other than those listed will denied without additional documentation.

Sources of Information

1998 CPT Book, American Medical Association,
Diagnostic Tests Handbook, Springhouse Corporation, 1987
Laboratory and Diagnostic Tests, Fifth Edition, Lippincott, 1996
Other Intermediaries' Policies
Medicare Special Bulletin B96-9, June 1996

Coding Guides

Use of the above ICD-9 codes does not guarantee reimbursement. Documentation requirements must be available if requested.

Codes must be reported at the highest level of specificity.

Documentation Required

ICD-9-CM diagnosis codes are required on claim.

Medical records must clearly document the medical necessity for the test and the frequency of the test.

If documentation is requested for review, submit the following:


Comments
Start Date of Comment Period: April 1, 1996
Start Date of Notice Period: June 1, 1997
Original Effective Date: July 1, 1997
Revised Effective Date: June 1, 1998

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 and the Carrier Advisory Committee.