CurrentHumanaPolicy LAB2023056

Laboratory Urine Culture Testing for Bacteria

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Humana Medicare Advantage payment policy describing reimbursement and coverage criteria for urine culture and related microbiology procedures for Humana members under Medicare Advantage plans.

Policy Summary

PayerHumana

PolicyLaboratory Urine Culture Testing for Bacteria

Policy CodePolicy LAB2023056

Change TypeNo material changes

Effective Date07/2023

Last ReviewJul 1, 2025

Next Review Date07/2025

Key ActionDo not bill urine culture testing codes when the primary diagnosis is a general encounter without abnormal findings; such claims are not reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7+procedure codes referenced for urine culture and susceptibility testing

Medicare Advantageproduct applicability

Not reimbursablebilling exclusion

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CurrentHumanaPolicy LAB2023056

Laboratory Urine Culture Testing for Bacteria

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Humana Medicare Advantage payment policy describing reimbursement and coverage criteria for urine culture and related microbiology procedures for Humana members under Medicare Advantage plans.

Policy Summary

PayerHumana

PolicyLaboratory Urine Culture Testing for Bacteria

Policy CodePolicy LAB2023056

Change TypeNo material changes

Effective Date07/2023

Last ReviewJul 1, 2025

Next Review Date07/2025

Key ActionDo not bill urine culture testing codes when the primary diagnosis is a general encounter without abnormal findings; such claims are not reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7+procedure codes referenced for urine culture and susceptibility testing

Medicare Advantageproduct applicability

Not reimbursablebilling exclusion

Medicare Advantage Urine Culture Coverage

Medicare Advantage urine culture coverage criteria

Humana's Medicare Advantage plans follow the criteria below and may defer to applicable Original Medicare LCDs.

Medicare Advantage urine culture testing is covered only when medical necessity and reasonableness requirements are met, and any applicable referral or authorization requirements are satisfied.

ALL of the following

NOT reimbursable when: Urine culture testing (CPT codes 87076, 87077, 87140, 87147, 87149, 87181, and 87186) is billed with a primary diagnosis representing a general encounter without abnormal findings or similar examination.

ALL of the following

Procedure codes: Applicable CPT codes: 87076, 87077, 87140, 87147, 87149, 87181, 87186.
Code descriptions (summary): 87076: Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate; 87077: Culture, bacterial (description referenced); 87140: Culture, typing; immunofluorescent method, each antiserum; 87147: Culture, typing; immunologic method, other than immunofluorescence, per antiserum; 87149: Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed; 87181: Susceptibility studies, antimicrobial agent; agar dilution method, per agent; 87186: Susceptibility studies, antimicrobial agent; microdilution or agar dilution (MIC or breakpoint) each multi-antimicrobial, per plate.

ALL of the following

Jurisdictional exception for 87149: Payment criteria for CPT 87149 apply to all Medicare jurisdictions except CGS Administrators, LLC; Noridian Healthcare Solutions, LLC; Palmetto GBA; and Wisconsin Physicians Service Insurance Corporation.
Refer to Original Medicare LCDs: When procedure code 87149 is subject to an Original Medicare Local Coverage Determination (MolDX LCDs), Humana follows the applicable LCD guidance (see linked MolDX LCDs for CGS, Noridian, Palmetto, and WPS).

Procedure Codes and Jurisdiction Notes

Urine culture and susceptibility procedure codesCPT

87076	Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate.
87077	Culture, bacterial (description referenced).
87140	Culture, typing; immunofluorescent method, each antiserum.
87147	Culture, typing; immunologic method, other than immunofluorescence, per antiserum.
87149	Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed.
87181	Susceptibility studies, antimicrobial agent; agar dilution method, per agent (e.g, antibiotic gradient strip).
87186	Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint) each multi-antimicrobial, per plate.

inv-03: 87149 jurisdictional exception

Jurisdictional applicabilityPayment criteria for CPT 87149 apply to all Medicare jurisdictions except CGS Administrators, LLC; Noridian Healthcare Solutions, LLC; Palmetto GBA; and Wisconsin Physicians Service Insurance Corporation.

Humana Medicare Advantage scopeHumana's Medicare Advantage payment criteria generally apply across MA plans but defer to Original Medicare LCDs where the procedure has established LCD criteria.

Referenced MolDX LCDsMolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing is the LCD policy title used by the listed MACs for procedure code 87149.

MACs named in exceptionThe specific MACs excluded from Humana’s 87149 payment criteria are CGS Administrators, Noridian Healthcare Solutions, Palmetto GBA, and WPS (Wisconsin Physicians Service).

Billing Guidance and Denial Risk

Denial Risk

Denial risk — urine culture not reimbursable with general encounter/normal findings

Urine culture testing (CPT codes 87076, 87077, 87140, 87147, 87149, 87181, 87186) will be denied when billed with a primary diagnosis that represents a general encounter without abnormal findings or a similar examination. To avoid denial, ensure the claim’s primary diagnosis documents an abnormal finding, symptom, or clinical indication that justifies urine culture testing rather than a general encounter/normal findings code.

Do not bill these urine culture CPT codes with a primary diagnosis indicating a general encounter without abnormal findings.
Document and submit a specific clinical diagnosis or symptom on the claim that supports medical necessity for the culture.

Not Reimbursable Scenarios and LCD Linkage

inv-05: Not reimbursable scenario

When not reimbursableUrine culture testing (CPT 87076, 87077, 87140, 87147, 87149, 87181, 87186) is not reimbursable when billed with a primary diagnosis representing a general encounter without abnormal findings or similar examination.

Affected procedure codesThis non‑reimbursable rule applies specifically to CPT codes 87076, 87077, 87140, 87147, 87149, 87181, and 87186.

Policy contextThis billing exclusion is part of Humana’s Medicare Advantage payment policy and applies unless an Original Medicare LCD establishes different criteria.

inv-06: Original Medicare LCD linkage

Linked Original Medicare LCDsProcedure code 87149 is addressed in MolDX LCDs from CGS Administrators, Noridian Healthcare Solutions, Palmetto GBA, and Wisconsin Physicians Service (WPS).

LCD policy title and focus