CurrentHumanaPolicy LAB2023056

Laboratory - Urine Culture Testing for Bacteria

Humana Medicare Advantage payment policy governing reimbursement for urine bacterial culture and susceptibility testing (specified CPT codes) for Medicare Advantage members; outlines non-reimbursable situations and references applicable LCDs and clinical guidance.

Policy Summary

PayerHumana

PolicyLaboratory - Urine Culture Testing for Bacteria

Policy CodePolicy LAB2023056

Change TypeNo material clinical or coverage changes

Effective Date07/2023

Next Review Date07/2025

Key ActionDo not bill urine culture and susceptibility testing for encounters coded as general encounter without abnormal findings; such claims are not reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7procedure codes referenced

Medicare Advantageapplicability

general encounternon-reimbursable scenario

07/2023–07/2025document dates

Medicare Advantage Reimbursement Criteria

Medicare Advantage reimbursement criteria

Applies to Medicare Advantage members; claims are subject to medical necessity and other plan requirements. Original Medicare LCDs apply where established (notably for procedure code 87149 under multiple MolDX LCDs).

Medicare Advantage reimbursement criteria for urine culture and susceptibility testing

ALL of the following

Applies to Medicare Advantage members; claims payments are subject to medical necessity, reasonableness, and applicable referral or authorization requirements.
Original Medicare Local Coverage Determinations (LCDs) apply where established; see MolDX LCDs referenced for procedure code 87149.

ALL of the following

Non-reimbursable scenario

Policy Summary

PayerHumana

PolicyLaboratory - Urine Culture Testing for Bacteria

Policy CodePolicy LAB2023056

Change TypeNo material clinical or coverage changes

Effective Date07/2023

Next Review Date07/2025

Key ActionDo not bill urine culture and susceptibility testing for encounters coded as general encounter without abnormal findings; such claims are not reimbursable.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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

Urine Culture and Susceptibility Testing Codes

Urine culture and susceptibility testing codesCPTCovered

87076	Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate
87077	Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87140	Culture, typing; immunofluorescent method, each antiserum
87147	Culture, typing; immunologic method, other than immunofluorescence (e.g., agglutination grouping), 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

Provider Billing and Authorization Guidance

Denial Risk

Prior Authorization / Reimbursement Restriction

Prior authorization / reimbursement restriction: Urine culture testing is not reimbursable when the primary diagnosis represents a general encounter without abnormal findings (e.g., visit codes indicating routine/general exam without signs or symptoms). Providers should obtain appropriate authorization and ensure the claim diagnosis supports medical necessity before billing.

Affected CPT codes: 87076, 87077, 87140, 87147, 87149, 87181, 87186
Denial risk: Claims with a primary/general encounter diagnosis without abnormal findings may be denied
Action: Verify primary diagnosis supports testing; obtain prior authorization if required by plan

Definitions and Test Descriptions

inv-04: Urine culture testing

CPT codes included87076, 87077, 87140, 87147, 87149, 87181, 87186

87076 descriptionCulture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate

87077 descriptionCulture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate

87140 descriptionCulture, typing; immunofluorescent method, each antiserum

87149 descriptionCulture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed

87181 & 87186 descriptions87181: 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