LCD/NCD Portal

NCD190.12 URINE CULTURE, BACTERIAL

 

 

Effective Date of this Version

• 1/1/2003

 

 

Benefit Category

 

• Diagnostic Laboratory Tests.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

 

Item/Service Description

 

• A bacterial urine culture is a laboratory procedure performed on a urine specimen to establish the probable etiology of a presumed urinary tract infection.

• It is common practice to do a urinalysis prior to a urine culture.

• A urine culture may also be used as part of the evaluation and management of another related condition.

• The procedure includes aerobic agar-based isolation of bacteria or other cultivable organisms present, and quantification of types present based on morphologic criteria.

• Isolates deemed significant may be subjected to additional identification and susceptibility procedures as requested by the ordering physician.

• The physician's request may be through clearly documented and communicated laboratory protocols.

 

 

Indications and Limitations of Coverage

 

Indications

 

• A patient's urinalysis is abnormal suggesting urinary tract infection, for example, abnormal microscopic (hematuria, pyuria, bacteriuria); abnormal biochemical urinalysis (positive leukocyte esterase, nitrite, protein, blood); a Gram's stain positive for microorganisms; positive bacteriuria screen by a non-culture technique; or other significant abnormality of a urinalysis.

 While it is not essential to evaluate a urine specimen by one of these methods before a urine culture is performed, certain clinical presentations with highly suggestive signs and symptoms may lend themselves to an antecedent urinalysis procedure where follow-up culture depends upon an initial positive or abnormal test result.

• A patient has clinical signs and symptoms indicative of a possible urinary tract infection (UTI).

 Acute lower UTI may present with urgency, frequency, nocturia, dysuria, discharge or incontinence.

 These findings may also be noted in upper UTI with additional systemic symptoms (for example, fever, chills, lethargy); or pain in the costovertebral, abdominal, or pelvic areas.

 Signs and symptoms may overlap considerably with other inflammatory conditions of the genitourinary tract (for example, prostatitis, urethritis, vaginitis, or cervicitis).

 Elderly or immunocompromised patients or patients with neurologic disorders may present atypically (for example, general debility, acute mental status changes, declining functional status).

• The patient is being evaluated for suspected urosepsis, fever of unknown origin, or other systemic manifestations of infection but without a known source.

 Signs and symptoms used to define sepsis have been well established.

• A test-of cure is generally not indicated in an uncomplicated infection.

 However, it may be indicated if the patient is being evaluated for response to therapy and there is a complicating co-existing urinary abnormality including structural or functional abnormalities, calculi, foreign bodies, or ureteral/renal stents or there is clinical or laboratory evidence of failure to respond as described.

• In surgical procedures involving major manipulations of the genitourinary tract, preoperative examination to detect occult infection may be indicated in selected cases (for example, prior to renal transplantation, manipulation or removal of kidney stones, or transurethral surgery of the bladder or prostate).

• Urine culture may be indicated to detect occult infection in renal transplant recipients on immunosuppressive therapy.

 

Limitations

 

• CPT 87086 may be used ONE time per encounter.

• Colony count restrictions on coverage of CPT 87088 do NOT apply as they may be highly variable according to syndrome or other clinical circumstances (for example, antecedent therapy, collection time, and degree of hydration).

• CPT 87088, 87184, and 87186 may be used multiple times in association with or independent of 87086, as urinary tract infections may be polymicrobial.

• Testing for asymptomatic bacteriuria as part of a prenatal evaluation may be medically appropriate but is considered screening and, therefore, NOT covered by Medicare.

 The US Preventive Services Task Force has concluded that screening for asymptomatic bacteriuria outside of the narrow indication for pregnant women is generally not indicated.

 There are insufficient data to recommend screening in ambulatory elderly patients including those with diabetes.

 Testing may be clinically indicated on other grounds including likelihood of recurrence or potential adverse effects of antibiotics, but is considered screening in the absence of clinical or laboratory evidence of infection.

• Note: Scroll down for links to the quarterly Covered Code Lists (including narrative).

 

 

Cross Reference

 

• Also see the Medicare Claims Processing Manual, Chapter 120, Clinical Laboratory Services Based on Negotiated Rulemaking.

 

 

Other

 

Covered Code Lists (including narrative)

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Coding Analyses for Labs (CALs)

 

• This NCD has been or is currently being reviewed under the National Coverage Determination process.

• The following are existing associations with CALs, from the Coding Analyses for Labs database.

• Original consideration for Coding Guidelines for Urine Culture (CAG-00298N)

• Original consideration for Urine Culture (Bacterial) and Serum Iron Studies (Revision of ICD-9-CM Codes for Pre-operative Examinations) (CAG-00236N)

• Original consideration for Urine Culture Bacterial (Re-evaluation of Inclusion of Renal Failure in the List of ICD-9-CM Codes Covered) (CAG-00195N)

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