2025 CPT code 81002
(Active) Effective Date: N/A Revision Date: N/A Laboratory - Urinalysis Procedures Pathology and Laboratory Procedures Feed
Manual urinalysis using a dipstick or tablet reagent to test for various urinary components; microscopy not included.
Modifiers may be applicable depending on the circumstances of service (e.g., modifier 99 for multiple procedures, or modifiers 90/91 for specific lab situations). Consult current coding guidelines for details.
Medical necessity for a urinalysis (81002) is established based on the patient's clinical presentation, symptoms, risk factors, and the need to assess kidney function, screen for urinary tract infections, or monitor existing conditions such as diabetes.
The clinical responsibility lies with the laboratory personnel who perform the test and interpret the results.The ordering physician is responsible for ordering the appropriate tests and interpreting the results in the context of the patient's clinical presentation.
In simple words: This lab test checks a urine sample using a special strip or tablet to measure different substances. It doesn't look at the urine under a microscope.
This CPT code encompasses a manual urinalysis procedure using either a dipstick or tablet reagent. The procedure involves the chemical analysis of a urine specimen to detect the presence and/or concentration of specific analytes, including but not limited to bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen. The results are obtained through visual interpretation of color changes on the reagent strip or tablet, compared to a color chart. Microscopic examination of the urine sediment is explicitly excluded from this code.
Example 1: A patient presents with symptoms suggestive of a urinary tract infection.A urinalysis (81002) is ordered to detect the presence of leukocytes, nitrites, and other indicators of infection., A patient with poorly controlled diabetes is monitored regularly with a urinalysis (81002) to assess for glucosuria (presence of glucose in the urine) and ketonuria (presence of ketones in the urine)., A patient undergoes a routine physical examination, including a urinalysis (81002) as part of a comprehensive health assessment to screen for various metabolic disorders and urinary tract abnormalities.
A properly collected urine sample is crucial.Documentation should include the date and time of collection, the method of collection (e.g., clean-catch midstream), and patient identification.The results of the dipstick or tablet test should be clearly documented, including the specific analytes tested and their corresponding semi-quantitative values.
** This code does not include microscopic examination of the urine sediment.Separate codes exist for microscopic urinalysis.Always refer to the most current CPT codebook for the most accurate coding and reimbursement information.
- Revenue Code: T1C (LAB TESTS - URINALYSIS)
- RVU: Information not available in source.RVUs vary by payer and location.
- Global Days: Not applicable.This is a laboratory test, not a surgical procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable; this is a complete laboratory procedure.
- Fee Schedule: Fee schedules vary significantly by payer and geographic location and change over time.Consult appropriate fee schedules for specific rates.
- Specialties:Urology, Internal Medicine, Family Medicine, Nephrology, Endocrinology, Pediatrics
- Place of Service:Office, Hospital, Clinical Laboratory, Urgent Care, etc.