LCD for Urinalysis (L1567)

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number 

00390 

Contractor Type 

FI 

LCD Information

LCD ID Number 

L1567 

LCD Title 

Urinalysis 

Contractor's Determination Number 

1567 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

CMS National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region 

Region IV

Original Determination Effective Date 

For services performed on or after 05/15/1998  

Original Determination Ending Date 

Revision Effective Date 

For services performed on or after 12/08/2005  

Revision Ending Date 

Indications and Limitations of Coverage and/or Medical Necessity 

A Urinalysis is a physical, chemical or microscopic examination of the urine.

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 which is known to affect the kidney/urinary tract. The following is a list of conditions in which a urinalysis will be considered medically necessary:

• The patient has symptoms suggestive of possible kidney/urinary tract disorder, e.g. 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, malodorous urine, edema, etc.
• The patient has been recently treated or is under treatment for a urinary tract disorder, and a repeat urinalysis is necessary to evaluate the patient.
• The patient has a condition known to affect the kidneys or urinary tract, such as hypertension, diabetes, collagen vascular disease, etc.
• The patient is undergoing treatment with a medication known to potentially adversely affect the kidneys, such as chemotherapy agents.
• The patient has sustained trauma affecting the genitourinary system.
• The patient has unexplained fever.
• The patient is pregnant and a urinalysis is performed as part of the prenatal care.
• Urine specific gravity determination can be covered as part of the evaluation of a dehydrated patient.
• The patient is scheduled for major a surgery and a urinalysis is being performed as part of the preoperative evaluation.

Coverage Topic 

Lab Services

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.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens
15x	Hospital-intermediate care - level I
16x	Hospital-intermediate care - level II
17x	Hospital-intermediate care - level III
18x	Hospital-swing beds
19x	Hospital-reserved for national assignment
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
24x	SNF-other (Part B)

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.

030X	Laboratory-general classification

CPT/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	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, WITH MICROSCOPY
81002	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, WITHOUT MICROSCOPY
81003	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, WITHOUT MICROSCOPY
81005	URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS
81007	URINALYSIS; BACTERIURIA SCREEN, EXCEPT BY CULTURE OR DIPSTICK
81015	URINALYSIS; MICROSCOPIC ONLY

ICD-9 Codes that Support Medical Necessity 

008.04	INTESTINAL INFECTION DUE TO ENTEROHEMORRHAGIC E. COLI
010.00 - 015.96	PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - TUBERCULOSIS OF UNSPECIFIED BONES AND JOINTS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
016.00 - 016.96	TUBERCULOSIS OF KIDNEY UNSPECIFIED EXAMINATION - UNSPECIFIED GENITOURINARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
017.00 - 018.90	TUBERCULOSIS OF SKIN AND SUBCUTANEOUS CELLULAR TISSUE UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS UNSPECIFIED EXAMINATION
034.0 - 034.1	STREPTOCOCCAL SORE THROAT - SCARLET FEVER
035	ERYSIPELAS
036.0 - 036.9	MENINGOCOCCAL MENINGITIS - MENINGOCOCCAL INFECTION UNSPECIFIED
038.9	UNSPECIFIED SEPTICEMIA
042	HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
054.10 - 054.19	GENITAL HERPES UNSPECIFIED - OTHER GENITAL HERPES
054.3	HERPETIC MENINGOENCEPHALITIS
072.0	MUMPS ORCHITIS
078.5 - 078.6	CYTOMEGALOVIRAL DISEASE - HEMORRHAGIC NEPHROSONEPHRITIS
079.88	OTHER SPECIFIED CHLAMYDIAL INFECTION
098.0 - 098.19	GONOCOCCAL INFECTION (ACUTE) OF LOWER GENITOURINARY TRACT - OTHER GONOCOCCAL INFECTION (ACUTE) OF UPPER GENITOURINARY TRACT
098.2 - 098.39	GONOCOCCAL INFECTION CHRONIC OF LOWER GENITOURINARY TRACT - OTHER CHRONIC GONOCOCCAL INFECTION OF UPPER GENITOURINARY TRACT
099.3 - 099.49	REITER'S DISEASE - OTHER NONGONOCOCCAL URETHRITIS OTHER SPECIFIED ORGANISM
100.0	LEPTOSPIROSIS ICTEROHEMORRHAGICA
112.1 - 112.2	CANDIDIASIS OF VULVA AND VAGINA - CANDIDIASIS OF OTHER UROGENITAL SITES
112.5	DISSEMINATED CANDIDIASIS
116.0	BLASTOMYCOSIS
117.7	ZYGOMYCOSIS (PHYCOMYCOSIS OR MUCORMYCOSIS)
120.0 - 120.2	SCHISTOSOMIASIS DUE TO SCHISTOSOMA HAEMATOBIUM - SCHISTOSOMIASIS DUE TO SCHISTOSOMA JAPONICUM
131.00 - 131.09	UROGENITAL TRICHOMONIASIS UNSPECIFIED - OTHER UROGENITAL TRICHOMONIASIS
185	MALIGNANT NEOPLASM OF PROSTATE
187.1 - 187.9	MALIGNANT NEOPLASM OF PREPUCE - MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED
188.0 - 188.9	MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED
189.0 - 189.9	MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS - MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED
198.0	SECONDARY MALIGNANT NEOPLASM OF KIDNEY
198.1	SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS
203.00 - 203.11	MULTIPLE MYELOMA WITHOUT REMISSION - PLASMA CELL LEUKEMIA IN REMISSION
222.1	BENIGN NEOPLASM OF PENIS
222.2	BENIGN NEOPLASM OF PROSTATE
222.8	BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF MALE GENITAL ORGANS
223.3	BENIGN NEOPLASM OF BLADDER
223.81	BENIGN NEOPLASM OF URETHRA
223.89	BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS
233.7	CARCINOMA IN SITU OF BLADDER
233.9	CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS
236.5	NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATE
236.7	NEOPLASM OF UNCERTAIN BEHAVIOR OF BLADDER
236.90	NEOPLASM OF UNCERTAIN BEHAVIOR OF URINARY ORGAN UNSPECIFIED
236.91	NEOPLASM OF UNCERTAIN BEHAVIOR OF KIDNEY AND URETER
236.99	NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED URINARY ORGANS
239.4	NEOPLASM OF UNSPECIFIED NATURE OF BLADDER
239.5	NEOPLASM OF UNSPECIFIED NATURE OF OTHER GENITOURINARY ORGANS
250.00 - 250.93	DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED
253.5 - 253.6	DIABETES INSIPIDUS - OTHER DISORDERS OF NEUROHYPOPHYSIS
271.4	RENAL GLYCOSURIA
273.0 - 273.9*	POLYCLONAL HYPERGAMMAGLOBULINEMIA - UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM
274.0 - 274.9	GOUTY ARTHROPATHY - GOUT UNSPECIFIED
276.0 - 276.9	HYPEROSMOLALITY AND/OR HYPERNATREMIA - ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED
277.00 - 277.7	CYSTIC FIBROSIS WITHOUT MECONIUM ILEUS - DYSMETABOLIC SYNDROME X
277.89	OTHER SPECIFIED DISORDERS OF METABOLISM
277.9	UNSPECIFIED DISORDER OF METABOLISM
282.60 - 282.63	SICKLE-CELL DISEASE UNSPECIFIED - SICKLE-CELL/HB-C DISEASE WITHOUT CRISIS
283.0 - 283.9	AUTOIMMUNE HEMOLYTIC ANEMIAS - ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED
289.7	METHEMOGLOBINEMIA
294.0 - 294.9	AMNESTIC DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE - UNSPECIFIED PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE
295.00 - 295.95	SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE - UNSPECIFIED TYPE SCHIZOPHRENIA IN REMISSION
296.10 - 296.25	MANIC AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE - MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
296.7	BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) UNSPECIFIED
298.8	OTHER AND UNSPECIFIED REACTIVE PSYCHOSIS
300.00 - 300.09	ANXIETY STATE UNSPECIFIED - OTHER ANXIETY STATES
306.50	PSYCHOGENIC GENITOURINARY MALFUNCTION UNSPECIFIED
306.53	PSYCHOGENIC DYSURIA
307.1	ANOREXIA NERVOSA
307.50	EATING DISORDER UNSPECIFIED
307.51	BULIMIA NERVOSA
401.0	MALIGNANT ESSENTIAL HYPERTENSION
401.1	BENIGN ESSENTIAL HYPERTENSION
401.9	UNSPECIFIED ESSENTIAL HYPERTENSION
402.00 - 402.91	MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
403.00 - 403.01	HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
403.10 - 403.11	HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
403.90 - 403.91	HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
404.00 - 404.93	HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
405.11 - 405.99	BENIGN RENOVASCULAR HYPERTENSION - OTHER UNSPECIFIED SECONDARY HYPERTENSION
428.0 - 428.9	CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED
446.0 - 446.7	POLYARTERITIS NODOSA - TAKAYASU'S DISEASE
447.6	ARTERITIS UNSPECIFIED
453.3	EMBOLISM AND THROMBOSIS OF RENAL VEIN
515	POSTINFLAMMATORY PULMONARY FIBROSIS
540.0 - 540.9	ACUTE APPENDICITIS WITH GENERALIZED PERITONITIS - ACUTE APPENDICITIS WITHOUT PERITONITIS
580.0 - 580.9	ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
581.0 - 581.9	NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
582.0 - 582.9	CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
583.0 - 583.9	NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
584.5 - 584.9	ACUTE RENAL FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE RENAL FAILURE UNSPECIFIED
585.1	CHRONIC KIDNEY DISEASE, STAGE I
585.2	CHRONIC KIDNEY DISEASE, STAGE II (MILD)
585.3	CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)
585.4	CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)
585.5	CHRONIC KIDNEY DISEASE, STAGE V
585.6	END STAGE RENAL DISEASE
585.9	CHRONIC KIDNEY DISEASE, UNSPECIFIED
586	RENAL FAILURE UNSPECIFIED
588.81*	SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN)
588.89*	OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION
588.9	UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION
590.00 - 590.9	CHRONIC PYELONEPHRITIS WITHOUT LESION OF RENAL MEDULLARY NECROSIS - INFECTION OF KIDNEY UNSPECIFIED
591	HYDRONEPHROSIS
592.0 - 592.9	CALCULUS OF KIDNEY - URINARY CALCULUS UNSPECIFIED
593.0 - 593.9	NEPHROPTOSIS - UNSPECIFIED DISORDER OF KIDNEY AND URETER
594.0 - 594.9	CALCULUS IN DIVERTICULUM OF BLADDER - CALCULUS OF LOWER URINARY TRACT UNSPECIFIED
595.0 - 595.9	ACUTE CYSTITIS - CYSTITIS UNSPECIFIED