Recent Comprehensive Error Rate Testing (CERT) analysis indicates increased errors when billing Urinalysis automated (UA), with microscopy CPTÂ® 81001. Upon medical review of the documentation submitted, the physician written order indicates UA test but does not indicate microscopy. Appropriate billing based on testing ordered is CPTÂ® 81003. Submitting a claim for diagnostic tests without the physician approval is a coding error.
The laboratory may have a protocol to complete a microscopy when the UA is ordered. However, protocols are not accepted by Medicare as orders. The physician must clearly document, in the medical record, his or her intent that a particular test(s) be performed.