Medicare and Aetna Denying Urinalysis | CPT Code 81002 with Modifier 25

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Alicia: We have another CPC one, 81002 with Modifier 25.

Q: Medicaid and Aetna are denying our urinalysis (81002), stating that they are included with the office visit. Would it be appropriate to bill it with a modifier 25?

A: Well, I found some really interesting information on this. I also cited the person who wrote the article that I found this on, very interesting. Here we go… she got a similar question that I found in this article. The difference was it was too specific, it says: We receive denials from Medicare for CPT code 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) and CPT code 82270 (Blood occult… one for feces to check for colorectal cancer). The remittance code indicates that we must submit a modifier; however, we cannot determine the appropriate modifier to report. Can you provide any advice? She sure does.

The answer she gave was: When the physician’s office performs this test in-house, you use modifier -92 (Alternative laboratory platform testing) may be applicable. The HCPCS modifier -QW (Clinical Laboratory Improvement Act waived test) you could also use that.

When the physician’s office employs an outside laboratory to perform the tests, you would report it was modifier -90 (Reference [outside] laboratory).

If this is not the first time the tests are being performed and reported for a particular patient, append modifier -91 (Repeat clinical diagnostic laboratory test).

Then, she goes on to say: When these tests are provided as part of a general colorectal cancer screening (in conjunction with [these are HCPCS codes] G0104, G0105, G0106, G0120, G0121, or G0122), the payer may request that you report modifier -51 (Multiple procedures) or modifier-59 (Distinct procedural service).

And that came from Shelley Safian from Safian Communications Services in Orlando, Florida. That’s some pretty savvy people in Florida that are coders.

That gives you an idea of the modifiers that might be appropriate for you to take care of that with your remittance advice that it’s coming in.

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