You Be the Coder: Be Cautious When Adding Urinalysis Code to E/M

Why This Topic Matters

Understanding the relationship between office urinalysis and E/M reporting helps avoid inappropriate claims, denials, and bundling issues in outpatient settings. It is especially relevant for practices that perform point-of-care testing and rely on staff-assisted documentation and billing workflows.

Article Sections

1. Question

   A reader asks about billing an office visit code together with a urinalysis test when staff collect the sample and review the results.

2. Answer

   The response addresses outpatient reporting considerations for urinalysis and evaluation and management services, including broader guidance on separate service reporting, bundling concerns, and staff-performed services.

3. Remember

   This section explains the need for a true evaluation and management service when reporting a low-level office visit in this context.

4. If there is a true E/M service

   This section discusses general circumstances in which office/outpatient evaluation and management services and laboratory testing may be reported separately.

5. Note

   This section covers incident-to billing context and the involvement of physician supervision when a nurse performs the service.