L29302-LCD

Automated World Health

Local Coverage Determination (LCD) for Urinalysis (L29302)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type

MAC - Part B

LCD Information

Document Information

LCD ID Number L29302

LCD Title Urinalysis

Contractor's Determination Number 81000

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Urinalysis is one of the most useful indicators of health and disease, and is especially helpful in the detection of renal or metabolic disorders. It aids in diagnosing and following the course of treatment in diseases of the kidney and urinary system and in detecting disorders in other parts of the body such as metabolic or endocrinologic abnormalities in which the kidneys function normally.

The components of a urinalysis include an evaluation of physical characteristics (color, odor, and opacity); determination of specific gravity and pH; detection and measurement of protein, glucose, and ketone bodies; and examination of sediment for blood cells, casts, and crystals. Some laboratories include screening for leukocyte esterase and nitrate and do not perform a microscopic examination unless one of the chemical screening (macroscopic) tests is abnormal or unless a specific request for microscopic examination is made.

Diagnostic laboratory methods include visual examination; reagent strip screening; refractometry for specific gravity; and microscopic inspection of centrifuged sediment.

Urinalysis can be performed either by automated instruments or the use of tablets, tapes or dipsticks. Dipsticks are chemically impregnated reagent (reactive) strips that allow for quick determination of pH, protein, glucose, ketones, bilirubin, hemoglobin, nitrate, leukocyte esterase, and urobilinogen. The tip of the dipstick is impregnated with chemicals that react with specific substances in the urine to produce colored end products. Color standards are provided against which the actual color can be compared. The reaction rates of the impregnated chemicals are standard for each dipstick, and color changes must be matched at the correct time after each stick is dipped into the urine specimen.

Normally, the color is straw to dark yellow, specific gravity 1.005-1.035, pH 4.5-8.0, normal urobilinogen, and negative for protein, glucose, ketones, bilirubin, hemoglobin, erythrocytes (RBCs), Nitrite (bacteria), and leukocytes (WBCs).

Medicare will consider a urinalysis study medically reasonable and necessary for the following conditions:

- Clinical symptomatology which may indicate a urinary system condition such as urgency; frequency; dysuria; flank pain; suprapubic discomfort; hematuria; fever of unknown origin; chills; swelling in the periorbital, abdominal and pedal areas of the body; heavy foaming urine, etc.;

- Physical examination reveals distended bladder with associated symptoms listed above;

- Patients on medications that are nephrotoxic (e.g., aminoglycosides); or

- Evaluation of patient’s response to treatment, such as antibiotic therapy for a UTI.

Conditions in which a urinalysis may be medically necessary are not limited to the following: urinary tract infection, glomerulonephritis, kidney stone, interstitial nephritis, nephrotic syndrome, acute renal failure, polynephritis, diabetic neuropathy, polycystic kidney disease, hyperplasia of prostate, rheumatoid arthritis, and renoparenchymal hypertension.

Even though a patient has a condition stated above, it is not expected that a urinalysis be performed frequently for stable chronic symptoms that are associated with that disease.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, 81000 LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE

CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY

URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, 81001 LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE

CONSTITUENTS; AUTOMATED, WITH MICROSCOPY

URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, 81002 LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE

CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY

URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, 81003 LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE

CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY

ICD-9 Codes that Support Medical Necessity N/A

XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the ordering/referring physician/nonphysician practitioner must indicate the medical necessity for performing the test including:

- office/progress notes

- laboratory results

If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, the provider of the service must maintain documentation of test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies. The physician/nonphysician practitioner must state the clinical indication/medical necessity for the study in his order for the test.

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Fischbach, F. (2003). A manual of laboratory and diagnostic tests (7th ed.). Philadelphia: Lippincott Williams & Wilkins.

Handrigan, M., Thompson, I., Foster, M. (2001). Genitourinary emergencies. Emergency Medicine Clinics of North America, Article 11952253. Retrieved July 20, 2004, from http://www.mdconsult.com.

Henry, J.B. (2001). Clinical diagnosis and management by laboratory methods (20th ed.). Philadelphia: W.B. Saunders.

Jacobs, D.S., Demott, W.R., Oxley, D.K. (2001). Laboratory test handbook (5th ed.). Ohio: Lexi-Comp Inc. Palmer, B. (2004). Approach to the patient with renal disease. ACP Medicine. Article 480448. Retrieved July 20,

2004, from http://www.medscape.com.

The National Heart, Lung, and Blood Institute. (2003). The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Retrieved July 20, 2004, from http://home.mdconsult.com.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29302) replaces LCD L6717 as the policy in notice. This document (L29302) is effective on 02/02/2009.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

81000 descriptor was changed in Group 1 81001 descriptor was changed in Group 1 81003 descriptor was changed in Group 1

Reason for Change