tci General Surgery Coding Alert - 2024 Issue Q2

You Be the Coder: Be Cautious When Adding Urinalysis Code to E/M

Question: For all lab tests performed in the office, our nurse researches the history, collects the sample, then gets the results. Can I therefore bill 99211 with urinalysis code 81002? AAPC Forum Participant Answer: No. CPT® guidelines prohibit reporting 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional) with 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) in...

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