Local Coverage Determination for Urinalysis Policy (L12728)

1 Local Coverage Determination (LCD) for Urinalysis Policy (L12728) Contractor InformationContractor NameNoridian Administrative Services, LLCC ontractor Number00320 Contractor TypeFIBack to TopLCD InformationDocument InformationLCD ID NumberL12728 LCD TitleUrinalysis PolicyContractor's Determination R14 AMA CPT/ADA CDT Copyright StatementCPT codes, descriptions and other data only are copyright2011 American Medical Association (or such other date ofpublication of CPT). All Rights Reserved. ApplicableFARS/DFARS Clauses Apply. Current Dental Terminology,(CDT) (including procedure codes, nomenclature,descriptors and other data contained therein) is copyrightby the American Dental Association.

2 2002, 2004 American Dental Association. All rights FARS/DFARS Geographic JurisdictionMinnesotaOversight RegionRegion VIIIO riginal Determination Effective DateFor services performed on or after 04/01/2003 Original Determination Ending DateRevision Effective DateFor services performed on or after 10/01/2011 Revision Ending DateCMS national Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(7). This section excludes routine physical XVIII of the Social Security Act, Section 1862(a)(1)(A) section allows Coverage and payment for only those servicesthat are considered to be reasonable and XVIII of the Social Security Act, Section 1833(e).

3 This section prohibits Medicare payment for any claim, whichlacks the necessary information to process the claim. Indications and Limitations of Coverage and/or Medical NecessityNote: Providers should seek information related to national Coverage Determinations (NCD) and other Centers forMedicare & Medicaid Services (CMS) instructions in CMS Manuals. This LCD only pertains to the contractor'sdiscretionary Coverage related to this is a commonly used physical, chemical, and/or microscopic examination of the urine used to detect renal orurinary tract disease or systemic disorders manifested by or through the urinary order for Medicare Coverage to be provided for Urinalysis , the patient must have signs or symptoms of a kidney/urinarytract disorder or a condition, which is known to affect the kidney/urinary tract.

4 The following is a list of conditions in whichurinalysis may be considered medically reasonable and necessary. The patient has symptoms suggestive of possible kidney/urinary tract disorder, , dysuria, frequency, hesitancy,nocturia, urgency, flank pain, pelvic pain, abdominal pain, etc. The patient exhibits signs of kidney/urinary tract disorder such as hematuria, discoloration of urine, edema andmalodorous on 10/6/2011. Page 1 of 43 The patient has been recently treated or is under treatment for urinary tract disorder and follow-up Urinalysis isnecessary to evaluate the patient. The patient has a condition known to affect the kidneys or urinary tract, , hypertension, diabetes mellitus, knownrenal disease, collagen vascular disease and a Urinalysis is necessary to evaluate the patient.

5 The patient is undergoing treatment with medication known to potentially adversely affect the kidneys, , goldtherapy. The patient has sustained trauma suggestive of possible kidney/urinary tract injury. The patient has unexplained fever. The patient is pregnant and Urinalysis is being done as part of standard prenatal patient is pregnant and Urinalysis is being done to screen for diabetic pre-eclampsia. Urinalysis can be covered as part of the evaluation of a dehydrated to TopCoding InformationBill Type Codes:Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this of a Bill Type does not guarantee that the Policy does not apply to that Bill Type.

6 Complete absence of all BillTypes indicates that Coverage is not influenced by Bill Type and the Policy should be assumed to apply equally to Inpatient (Medicare Part B only)013xHospital Outpatient014xHospital - Laboratory Services Provided to Non-patients022xSkilled Nursing - Inpatient (Medicare Part B only)023xSkilled Nursing - Outpatient085xCritical Access HospitalRevenue Codes:Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report thisservice. In most instances Revenue Codes are purely advisory; unless specified in the Policy services reported underother Revenue Codes are equally subject to this Coverage Determination .

7 Complete absence of all Revenue Codesindicates that Coverage is not influenced by Revenue Code and the Policy should be assumed to apply equally to allRevenue - General Classification031 XLaboratory Pathology - General ClassificationCPT/HCPCS CodesGroupName81000 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, WITHMICROSCOPY81001 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, WITHMICROSCOPY81002 Urinalysis , BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE,HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY,UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS.

8 NON-AUTOMATED,WITHOUT MICROSCOPY81003 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, WITHOUTMICROSCOPY81005 Urinalysis ; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYSP rinted on 10/6/2011. Page 2 of 43 81007 Urinalysis ; BACTERIURIA SCREEN, EXCEPT BY CULTURE OR DIPSTICK81015 Urinalysis ; MICROSCOPIC ONLY81020 Urinalysis ; 2 OR 3 GLASS TESTICD-9 Codes that Support Medical OF KIDNEY UNSPECIFIED OF KIDNEY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATIONNOT OF KIDNEY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATIONRESULTS UNKNOWN (AT PRESENT) OF KIDNEY TUBERCLE BACILLI FOUND (IN SPUTUM) OF KIDNEY TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BYMICROSCOPY BUT FOUND BY BACTERIAL OF KIDNEY TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICALEXAMINATION BUT TUBERCULOSIS CONFIRMED OF KIDNEY TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICALOR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHERMETHODS (INOCULATION OF ANIMALS)

9 OF BLADDER UNSPECIFIED OF BLADDER BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATIONNOT OF BLADDER BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATIONRESULTS UNKNOWN (AT PRESENT) OF BLADDER TUBERCLE BACILLI FOUND (IN SPUTUM) OF BLADDER TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BYMICROSCOPY BUT FOUND BY BACTERIAL OF BLADDER TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICALEXAMINATION BUT TUBERCULOSIS CONFIRMED OF BLADDER TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICALOR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHERMETHODS (INOCULATION OF ANIMALS) OF URETER UNSPECIFIED OF URETER BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATIONNOT OF URETER BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATIONRESULTS UNKNOWN (AT PRESENT) OF URETER TUBERCLE BACILLI FOUND (IN SPUTUM) OF URETER TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BYMICROSCOPY BUT FOUND BY BACTERIAL OF URETER TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICALEXAMINATION BUT TUBERCULOSIS CONFIRMED OF URETER TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICALOR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHERMETHODS (INOCULATION OF ANIMALS)

10 OF OTHER URINARY ORGANS UNSPECIFIED OF OTHER URINARY ORGANS BACTERIOLOGICAL OR HISTOLOGICALEXAMINATION NOT OF OTHER URINARY ORGANS BACTERIOLOGICAL OR HISTOLOGICALEXAMINATION RESULTS UNKNOWN (AT PRESENT) OF OTHER URINARY ORGANS TUBERCLE BACILLI FOUND (INSPUTUM) BY MICROSCOPYP rinted on 10/6/2011. Page 3 of 43 OF OTHER URINARY ORGANS TUBERCLE BACILLI NOT FOUND (INSPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL OF OTHER URINARY ORGANS TUBERCLE BACILLI NOT FOUND BYBACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS OF OTHER URINARY ORGANS TUBERCLE BACILLI NOT FOUND BYBACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSISCONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) OF EPIDIDYMIS UNSPECIFIED OF EPIDIDYMIS BACTERIOLOGICAL OR HISTOLOGICALEXAMINATION NOT OF EPIDIDYMIS BACTERIOLOGICAL OR HISTOLOGICALEXAMINATION RESULTS UNKNOWN (AT PRESENT)