2025 CPT code 81000
(Active) Effective Date: N/A Revision Date: N/A Laboratory - Urinalysis Procedures Pathology and Laboratory Feed
Manual urinalysis with microscopy, using dipstick or tablet reagent to analyze multiple urinary components.
Modifiers such as 59 (distinct procedural service), 90 (reference laboratory), 91 (repeat test), and 99 (multiple modifiers) may be applicable depending on the clinical scenario.
Medical necessity for urinalysis varies based on the patient's clinical presentation and clinical indications.Examples include but are not limited to suspected UTIs, evaluation of kidney function, monitoring of diabetes, and investigation of hematuria.
A laboratory analyst is responsible for performing the urinalysis, including the chemical analysis and microscopic examination.
In simple words: This lab test checks your urine for different substances using a special strip or tablet. It also looks at the urine under a microscope to check for cells and other things that might show a health problem.
This CPT code encompasses a non-automated urinalysis involving a dipstick or tablet reagent test for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen.The analysis includes a microscopic examination of centrifuged urine sediment to identify cellular elements (e.g., white blood cells, red blood cells, epithelial cells, bacteria), casts, crystals, and other components. Results are reported semi-quantitatively (e.g., trace, 1+, 2+, 3+, 4+) or in mg/dL.
Example 1: A patient presents with symptoms suggestive of a urinary tract infection (UTI). A urinalysis (81000) is ordered to detect the presence of bacteria, leukocytes, and other indicators of infection., A patient with diabetes is monitored for kidney function.Regular urinalysis (81000) helps assess proteinuria, glycosuria, and other indicators of kidney damage., A patient undergoes a routine health check-up.A basic urinalysis (81000) is included to screen for abnormalities such as hematuria or abnormal levels of protein or glucose.
* Patient's demographic information.* Date and time of urine collection.* Appropriately labeled urine specimen.* Physician's order specifying the requested analytes and procedures.* Results of the chemical analysis (dipstick or tablet reagent).* Microscopic examination report detailing cellular components, casts, crystals, and other findings.* Interpretation and clinical correlation by a qualified pathologist or physician.
** Accurate reporting requires precise documentation of the method used (dipstick vs. tablet), analytes tested, and microscopic findings.This code should not be used in conjunction with individual analyte codes (unless justified by medical necessity and modifier use).The microscopic examination is a critical component of this code and should be adequately documented.
- Revenue Code: T1C (LAB TESTS - URINALYSIS)
- RVU: Information on RVUs varies by payer and location.Consult your local fee schedule.
- Global Days: Not applicable; this is a laboratory test.
- Payment Status: Active
- Modifier TC rule: Modifier TC (technical component) is not typically used with 81000 since this represents the complete procedure including both the technical and professional components.
- Fee Schedule: Fee schedules are payer-specific and change over time; therefore, historical data requires consultation with your payer's specific fee schedule information.
- Specialties:Urology, Nephrology, Internal Medicine, Family Medicine, Pediatrics
- Place of Service:Office, Hospital (Inpatient and Outpatient), Clinical Laboratory, Urgent Care Facility