A bacterial urine culture is a laboratory procedure performed on a urine specimen to establish the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a urine culture. A urine culture may also be used as part of the evaluation and management of another related condition. The procedure includes aerobic agar-based isolation of bacteria or other cultivable organisms present, and quantification of types present based on morphologic criteria. Isolates deemed significant may be subjected to additional identification and susceptibility procedures as requested by the ordering physician. The physician's request may be through clearly documented and communicated laboratory protocols.

Indications

1. A patient's urinalysis is abnormal suggesting urinary tract infection, for example, abnormal microscopic (hematuria, pyuria, bacteriuria); abnormal biochemical urinalysis (positive leukocyte esterase, nitrite, protein, blood); a Gram's stain positive for microorganisms; positive bacteriuria screen by a non-culture technique; or other significant abnormality of a urinalysis.  While it is not essential to evaluate a urine specimen by one of these methods before a urine culture is performed, certain clinical presentations with highly suggestive signs and symptoms may lend themselves to an antecedent urinalysis procedure where follow-up culture depends upon an initial positive or abnormal test result.
2. A patient has clinical signs and symptoms indicative of a possible urinary tract infection (UTI).  Acute lower UTI may present with urgency, frequency, nocturia, dysuria, discharge or incontinence.  These findings may also be noted in upper UTI with additional systemic symptoms (for example, fever, chills, lethargy); or pain in the costovertebral, abdominal, or pelvic areas.  Signs and symptoms may overlap considerably with other inflammatory conditions of the genitourinary tract (for example, prostatitis, urethritis, vaginitis, or cervicitis).  Elderly or immunocompromised patients, or patients with neurologic disorders may present atypically (for example, general debility, acute mental status changes, declining functional status).
3. The patient is being evaluated for suspected urosepsis, fever of unknown origin, or other systemic manifestations of infection but without a known source.  Signs and symptoms used to define sepsis have been well-established.
4. A test-of cure is generally not indicated in an uncomplicated infection.  However, it may be indicated if the patient is being evaluated for response to therapy and there is a complicating co-existing urinary abnormality including structural or functional abnormalities, calculi, foreign bodies, or ureteral/renal stents or there is clinical or laboratory evidence of failure to respond as described in Indications 1 and 2.
5. In surgical procedures involving major manipulations of the genitourinary tract, preoperative examination to detect occult infection may be indicated in selected cases (for example, prior to renal transplantation, manipulation or removal of kidney stones, or transurethral surgery of the bladder or prostate).
6. Urine culture may be indicated to detect occult infection in renal transplant recipients on immunosuppressive therapy.

Limitations

1. CPT 87086 may be used one time per encounter.
2. Colony count restrictions on coverage of CPT 87088 do not apply as they may be highly variable according to syndrome or other clinical circumstances (for example, antecedent therapy, collection time, degree of hydration).
3. CPT 87088, 87184, and 87186 may be used multiple times in association with or independent of 87086, as urinary tract infections may be polymicrobial.
4. Testing for asymptomatic bacteriuria as part of a prenatal evaluation may be medically appropriate but is considered screening and, therefore, not covered by Medicare.  The US Preventive Services Task Force has concluded that screening for asymptomatic bacteriuria outside of the narrow indication for pregnant women is generally not indicated.  There are insufficient data to recommend screening in ambulatory elderly patients including those with diabetes.  Testing may be clinically indicated on other grounds including likelihood of recurrence or potential adverse effects of antibiotics, but is considered screening in the absence of clinical or laboratory evidence of infection.

With the exception of routine or screening, any diagnosis other than those listed under the “Covered Diagnosis Codes” section will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Bacterial urine culture testing for routine or screening purposes is excluded from coverage.  Therefore, any diagnosis code listed under the “Screening Diagnosis Codes” section will deny as not covered. The provider can bill the member for the denied service.

NOTE:

A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without a diagnosis code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. Also, if a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency.

Documentation Requirements

Failure to provide documentation of the medical necessity of tests may result in denial of claims.  Such documentation may include notes documenting relevant signs, symptoms or abnormal findings that substantiate the medical necessity for ordering the tests.  In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Use CPT 87086 Culture, bacterial, urine; quantitative, colony count where a urine culture colony count is performed to determine the approximate number of bacteria present per milliliter of urine.  The number of units of service is determined by the number of specimens.

Use CPT 87088 where a commercial kit uses manufacturer defined media for isolation, presumptive identification, and quantitation of morphotypes present.  The number of units of service is determined by the number of specimens.

Use CPT 87088 where identification of morphotypes recovered by quantitative culture or commercial kits and deemed to represent significant bacteriuria requires the use of additional testing, for example, biochemical test procedures on colonies.  Identification based solely on visual observation of the primary media is usually not adequate to justify use of this code.  The number of units of service is determined by the number of isolates.

Use CPT 87184 or 87186 where susceptibility testing of isolates deemed to be significant is performed concurrently with identification. The number of units of service is determined by the number of isolates.  These codes are not exclusively used for urine cultures but are appropriate for isolates from other sources as well.

Appropriate combinations are as follows: CPT 87086, 1 per specimen with 87088, 1 per isolate and 87184 or 87186 where appropriate.

Culture for other specific organism groups not ordinarily recovered by media used for aerobic urine culture may require use of additional CPT codes (for example, anaerobes from suprapubic samples).

Identification of isolates by non-routine, nonbiochemical methods may be coded appropriately (for example, immunologic identification of streptococci, nucleic acid techniques for identification of N. gonorrhoeae).

While infrequently used, sensitivity studies by methods other than CPT 87184 or 87186 are appropriate. CPT 87181, agar dilution  method, each antibiotic or CPT 87188, macrotube dilution  method, each antibiotic may be used. The number of units of service is the number of antibiotics multiplied by the number of unique isolates.

Diagnosis code 780.02, 780.9 or 799.3 should be used only in the situation of an elderly patient, immunocompromised patient or patient with neurologic disorder who presents without typical manifestations of a urinary tract infection but who presents with one of the following signs or symptoms, not otherwise explained by another co-existing condition:  increasing debility; declining functional status; acute mental changes; changes in awareness; or hypothermia.

In cases of post renal-transplant urine culture used to detect clinically significant occult infection in patients on long term immunosuppressive therapy, use code V58.69.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

National Coverage Determination - 190.12

On-Line NCD Coding Policy Manual and Change Report

Transmittal 651, CR 4005

Transmittal 758, CR 4161

Transmittal 864, CR 4328

Transmittal 1050, CR 5293

Transmittal 1606, CR 6213

Transmittal 1645, CR 6304

Transmittal 1766, CR 6548

Transmittal 1963, CR 6964

Transmittal 2001, CR 7057

Covered Diagnosis Codes

The following diagnosis codes are specifically related to the reporting of codes 87086 and 87088.

Noncovered Diagnosis Codes

Screening Diagnosis Codes