2025 CPT code 81015
(Active) Effective Date: N/A Revision Date: N/A Laboratory - Urinalysis Procedures Pathology and Laboratory Feed
Microscopic urinalysis; examination of urine sediment for cellular elements, crystals, and other components.
Modifiers may be applicable depending on the circumstances, such as location of service and other factors. Consult NCCI edits and payer specific guidelines.
Medical necessity for a microscopic urinalysis (81015) is established based on clinical findings suggesting urinary tract pathology (e.g., hematuria, dysuria, suspected infection), the need for renal function assessment, or to further investigate abnormal urinalysis results.The specific clinical indication should be documented in the medical record.
A laboratory analyst performs this test.The ordering physician interprets the results in the context of the patient’s clinical presentation.
In simple words: This lab test examines a urine sample under a microscope to look for cells, crystals, and other tiny particles. This helps to identify possible problems in the urinary tract or kidneys.
This CPT code 81015 represents a microscopic urinalysis, focusing solely on the microscopic examination of urine sediment.The procedure involves the analysis of a urine specimen (typically a clean-catch sample) under a microscope, after centrifugation to concentrate the sediment.The lab analyst identifies and reports the presence of cellular elements (white blood cells, red blood cells, epithelial cells), casts, crystals, parasites, and other microscopic objects.Direct examination of unconcentrated urine may also be performed. This code is used when the microscopic examination is ordered independently, without accompanying chemical tests (dipstick urinalysis).
Example 1: A patient presents with suspected urinary tract infection (UTI).A microscopic urinalysis (81015) is ordered to assess for the presence of white blood cells, bacteria, and other indicative microscopic elements., A patient with known kidney disease undergoes routine monitoring.A microscopic urinalysis (81015) is performed to evaluate for the presence of casts, red blood cells, and other indicators of kidney damage., A patient presents with hematuria (blood in urine).To determine the source, microscopic examination (81015) is performed to differentiate between glomerular bleeding (red blood cell casts) and lower urinary tract bleeding (free red blood cells).
* Physician's order specifying microscopic urinalysis only.* Properly labeled urine specimen (patient identification, date, time of collection).* Detailed microscopic examination report indicating the findings (cells, casts, crystals, other elements).* Documentation of the method used for specimen preparation (centrifugation, direct examination).
** This code should not be used if a complete urinalysis (including chemical and microscopic examinations) is performed.Always refer to the most current CPT codebook and payer guidelines for accurate coding and reimbursement.
- Revenue Code: T1C (LAB TESTS - URINALYSIS)
- RVU: Information not available in provided sources.RVUs vary by payer and location.
- Global Days: Not applicable to this laboratory procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable; this is a laboratory procedure.
- Fee Schedule: Historical fee schedule data not available in the provided sources. Fee schedules vary by payer and location and are subject to change.
- Specialties:Urology, Nephrology, Internal Medicine, Family Medicine
- Place of Service:Office, Hospital (Inpatient and Outpatient), Clinical Laboratory, Urgent Care Facility