CPT Code 81002 urinalysis by dipstick

Last Updated on September 30, 2025

CPT Code 81002 reports a manual (non-automated) urinalysis by dipstick or tablet reagent performed without microscopy. To simply understand,: a staff member visually compares the strip’s color pads to the manufacturer’s chart and records the result; no analyzer reads it and no microscopic exam is performed. 

One unit of 81002 covers any number of strip analytes (leukocyte esterase, nitrite, blood, protein, glucose, ketones, pH, specific gravity, bilirubin, urobilinogen). AAPC’s guidance and code descriptor explicitly anchor 81002 to this visual, non-automated method and no microscopy.

What CPT 81002 includes

Included with 81002

• Method: manual, visual color comparison of a dipstick or tablet reagent (no device interprets the strip).
• Scope: any number of chemical constituents on the strip, still one line, one unit
• Setting: typical in primary care, urgent care, pediatrics, occupational health, and small clinics.

if an analyzer reads the strip, that’s automated testing and falls outside 81002; if microscopy is performed, you’ve moved to a different family (for example, a with-microscopy code such as 81001). The deciding factor for 81002 is the manual/visual method with no microscopy, state that clearly in the note.

Documentation to prevent denials

Auditors and payers look for five small things. Add them to your EHR template and you’ll solve most issues:

• Indication: “UA ordered for dysuria/fever/flank pain/dehydration check/diabetes screen.”
• Method line: “Manual visual dipstick read against manufacturer color chart.” (This proves non-automated.)
• Analytes recorded: LE, nitrite, blood, protein, glucose, ketones, pH, specific gravity, bilirubin, urobilinogen.
• Result summary + impact: “LE+, nitrite+, trace blood; findings support UTI, plan documented.”
• If repeated the same day: one sentence explaining why you repeated and how you used the second result.

These five elements address medical necessity, the exact method that defines 81002, and how results informed care, all things reviewers flag when they’re missing.

CLIA and QW for 81002

• CLIA-waived: 81002 is a waived test under CLIA.
• QW modifier: not required for 81002 to be recognized as waived. CMS repeats this exception in multiple MLN transmittals (for example, MM13455 and MM12841). Keep your site’s CLIA certificate current; you don’t need QW on the claim line for 81002.
• Retro lookbacks: CMS notes MACs won’t search files to take back or repay claims over these exceptions; they’ll adjust specific claims you bring to them. Useful if you’re cleaning up past submissions.

Template line to add under your lab result: CLIA: Waived. CMS MLN confirms QW not required for 81002. Cert ID: ______; Expires: ______. Reader initials: ______; Date/Time: ______.

Billing rules

• Units of service: One. Even if you check all pads on the strip, 81002 is billed once per encounter. (The code descriptor itself says “any number of these constituents.)
• Who can perform it: Follow your state scope and clinic policy. From a coding perspective, the claim follows the ordering/rendering provider rules in your contract; method and documentation decide the code.
• Turnaround and storage: These aren’t coding details, but IFU timing (how long after dip) and lot/expiry logging belong in your lab SOP. A line capturing strip lot/expiry and read time strengthens audit readiness.

81002 on the same day as an E/M

You’ll see two patterns in the market:

• Bundled by policy: Some payers do not separately reimburse 81002 when billed with a same-day E/M by the same provider for the same member. Horizon Blue Cross states this explicitly; they pay the E/M and bundle 81002 (and 81003). EmblemHealth publishes a similar edit. In these plans, adding 25 to the E/M or 59 to the UA generally won’t change the outcome. Build this into your payer matrix so staff don’t chase non-payable lines.
  
• Separately payable when distinct: Other payers will pay 81002 in addition to an E/M if there’s a significant, separately identifiable visit and your documentation shows history, exam, and decision-making beyond the lab result alone. Trade publications consistently warn that results will vary, and to rely on documented policy rather than blanket modifier fixes.

Operational tip: Keep a one-page payer matrix: (A) always bundles UA with E/M vs (B) pays when distinct E/M is documented, and route claims accordingly. That single page reduces resubmits and staff back-and-forth.

Modifiers for CPT Code 81002

• 91 — Repeat clinical diagnostic laboratory test – Use when you repeat the same test on the same day to obtain subsequent results for active management (e.g., reassessing dehydration or response to therapy). Don’t use 91 for QC, equipment problems, or specimen errors. Add one sentence in the note tying the repeat to clinical action.
• 25 — Significant, separately identifiable E/M – If your payer allows separate payment for a same-day visit and the UA, 25 goes on the E/M (not on 81002). For plans that publish bundling, 25 won’t override their rule—follow the matrix.
• 59 — Distinct procedural service – Rarely appropriate for this situation. AAPC cautions that while some try 59 when UA is denied with E/M, many payers still bundle by policy. Don’t build 59 into your standard workflow.

If your contracts require it for send-outs, 90 may apply when the test is referred to a reference lab; that’s payer-specific and doesn’t change the definition of 81002.

Denials to expect

Bundled with E/M

• Cause: Payer policy (e.g., Horizon, EmblemHealth).
• Prevention: On your matrix, mark these payers “bundle UA with E/M.” Submit the visit only; don’t resubmit the UA line. If a plan pays when distinct, ensure the visit is truly separate and 25 is on the E/M. Horizon Blue+1

Wrong method code

• Cause: The note never says manual/visual vs analyzer.
• Prevention: Add the method line to your template and train staff never to skip it. This single sentence drives 81002 (manual) versus automated testing.

Repeat not medically necessary (91 rejected)

• Cause: No clinical reason was documented for the same-day repeat.
• Prevention: Add one line explaining why you needed a second result and how it changed care (e.g., fluid challenge, antibiotic start, response reassessment).

CLIA/QW problem

• Cause: Payer flags missing/incorrect CLIA or expects QW.
• Prevention: Put your CLIA certificate number on claims; if QW is requested for 81002, appeal with CMS MLN that 81002 does not require QW to be recognized as waived.