Overview
CPT® Code 81000 is used to report manual urinalysis using dip stick or tablet reagent with non-automated microscopy. This test evaluates the chemical and physical properties of urine and allows microscopic examination of cells, casts, crystals, and other urinary components.
Unlike automated urinalysis, CPT 81000 represents manual processing and microscopy, providing clinicians with direct, hands-on assessment of urine specimens. Interpretation and clinical counseling are not included in the code.
Key Facts About CPT® 81000
- Service type: Urinalysis with microscopy, non-automated
- Provider type: Physicians, laboratories, or qualified healthcare professionals
- Medical services included: Yes—chemical analysis via dip stick or tablet and microscopic evaluation of urine sediment
- Specimen type: Urine (random, clean-catch, catheterized, or timed specimen)
- Common clinical indications:
- Screening for urinary tract infections
- Evaluation of hematuria or proteinuria
- Monitoring kidney disease or renal function
- Assessment of metabolic or systemic disorders
When to Use CPT® 81000
CPT 81000 is appropriate when:
- A urine specimen is analyzed manually using dip stick/tablet reagents
- Microscopic examination is performed without automation
- Testing is medically necessary for diagnosis, monitoring, or follow-up
Examples:
- Screening a patient with suspected urinary tract infection using dip stick and microscope
- Evaluating proteinuria in a patient with chronic kidney disease
Documentation Requirements
To properly support CPT 81000 billing, documentation should include:
- Patient identifiers and date of service
- Specimen type and collection method
- Chemical and physical results from the dip stick/tablet
- Microscopic findings (cells, casts, crystals)
- Clinical indication for testing
- Any follow-up recommendations
Accurate documentation ensures compliance, reimbursement, and continuity of care.
Reimbursement and Coding Considerations
- CPT 81000 is covered by most commercial insurers and Medicare when medically necessary
- Interpretation and follow-up are billed separately
- Modifier use may be required when multiple lab tests are performed on the same specimen
- Always verify payer-specific rules and bundled lab panel policies
How OptiMantra Supports Urinalysis
OptiMantra’s integrated EMR and practice management system streamlines urinalysis workflows, including CPT 81000:
With OptiMantra, providers can:
- Link urinalysis orders directly to the patient’s chart for longitudinal tracking
- Record dip stick results and microscopic findings in structured templates
- Track trends in renal function, infections, or metabolic changes
- Generate clean, audit-ready billing codes
- Integrate urinalysis results with broader care plans
By centralizing urinalysis documentation and billing, OptiMantra helps practices maintain accurate records, improve patient care, and ensure proper reimbursement.
Try OptiMantra for free here!
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