Good question. I like to refer to CMS's Lab NCD 23. Item 190.12 discusses Urine cultures. It calls out the 4 hot dipstick items (Leukocyte esterase, blood, nitrites and protein) plus microscopic findings of WBC, RBC and/or bacteria that may indicate that a culture is needed. http://http://www.cms.gov/CoverageGenInfo/04_LabNCDs.asp But, it also indicates that a patient's symptoms may also indicate a need for a urine culture. To empower the physician to place orders that are "Reasonable and Medically Necessary", we built three different test groups in Meditech 6.0. 1. Urinalysis (dip and micro if indicated) the doctor would need to specifically add a culture. 2. UA w Culture if Indicated (CIF) (Reflex policy needed) 3. UA and culture The Executive Medical Committee at your hospital would need to define the reflex lab test policy, review once a year and get sign-off from medical staff that they understand the policy.(Per Office of Inspector General policy) Finally, consider that with the advent of ARRA, CMS can withhold payment if they think a UTI was obtained while in the hospital. Your lab director, lab teams and hospital quality assurance team need to have a conversation about whether to error on the side of caution to perform a few more cultures than needed.....as opposed to not getting paid for a DRG. Yikes.
