Urinalysis with Evaluation and Management (E&M) Services

Reimbursement Policy:
Urinalysis with Evaluation and Management (E&M) Services

Effective Date:
January 1, 2013

Last Revised Date:
March, 10, 2015

Purpose:
This policy provides guidelines for reimbursement when a urinalysis procedure code is billed in conjunction with an Evaluation and Management Service (E&M), on the same day, for the same member, by the same provider. This policy shall apply to participating and non-participating professional providers.

Scope
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home PAR
  • ITS Host Medicare Advantage PPO Non-Par

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Urinalysis procedures (81002 or 81003) when billed in conjunction with any E&M service will not be separately reimbursed when a modifier 25 is appended to the E&M service or a modifier 59 is appended to the urinalysis procedure, on the same day, for the same member, by the same provider, on the same or different claims.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued, until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Maintain the incidental or mutually exclusive edit on the urinalysis procedure code (81002 and 81003) whether or not a modifier is appended. The edit cannot be overridden and the urinalysis procedure will not be reimbursed separately.

When a urinalysis code (81002 or 81003) is submitted with any E&M Service, on the same day, for the same member, by the same provider (same or different claims), only the E&M Service will be eligible for reimbursement.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

 

CPT® is a registered trademark of the American Medical Association.

Policy 068_v2.0_03102015