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Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

CPT4 code

Name of the Procedure:

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy.

Summary

Urinalysis is a common diagnostic test that examines the content of urine using dipsticks or tablet reagents for various constituents like bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen. The test can also be automated and involves microscopic examination for a more detailed analysis.

Purpose

This procedure helps in diagnosing and monitoring various medical conditions such as urinary tract infections, kidney disease, diabetes, liver disease, and other metabolic conditions. The goal is to detect abnormalities in the urine that could indicate underlying health issues.

Indications

  • Symptoms of a urinary tract infection (e.g., burning sensation during urination, cloudy urine)
  • Monitoring of chronic conditions like diabetes and kidney disease
  • Routine health check-ups
  • Unexplained back or abdominal pain
  • Presence of blood in the urine (hematuria)
  • Monitoring treatment effectiveness for certain metabolic disorders

Preparation

  • No special fasting or preparation is generally required.
  • It's best to collect the first morning urine sample, as it is more concentrated.
  • Inform the healthcare provider of any medications being taken, as some drugs can affect test results.

Procedure Description

  1. Collection: The patient provides a urine sample in a sterile container.
  2. Testing: A dipstick or tablet reagent is dipped into the urine or a small amount of urine is dropped onto a tablet reagent.
  3. Analysis: The dipstick or tablet changes color, indicating the presence of specific constituents. Results are compared against a color chart.
  4. Automation and Microscopy: Samples may be placed in an automated machine for further analysis, including microscopic examination of cells, crystals, and bacteria in the urine.
Tools/Equipment Used
  • Sterile urine container
  • Dipstick or tablet reagent
  • Automated urinalysis machine (if applicable)
  • Microscope

Duration

The procedure typically takes about 5-10 minutes.

Setting

Generally performed in a healthcare provider's office, outpatient clinic, or hospital.

Personnel

  • Primary care physicians, nurses, or lab technicians usually perform the initial part of the test.
  • A clinical laboratory scientist or pathologist may be involved in the microscopy and detailed analysis.

Risks and Complications

  • Very minimal risks, primarily limited to sample contamination.
  • Rarely, an inaccurate result might warrant a repeat test.

Benefits

  • Provides quick, non-invasive diagnostic information.
  • Helps in the early detection and monitoring of various health conditions.
  • Results are typically available in a short timeframe, often during the same visit.

Recovery

  • No recovery time is needed.
  • Patients can resume normal activities immediately after providing the sample.

Alternatives

  • Blood tests may provide similar information about some health conditions but are more invasive.
  • Imaging studies like ultrasound may be used to investigate kidney or bladder issues but won't provide metabolic information.

Patient Experience

  • The process involves simply urinating into a sterile container.
  • Minimal discomfort, primarily associated with providing the sample under potentially awkward conditions.
  • No pain management or sedation is required; the patient remains comfortable throughout the procedure.

Medical Policies and Guidelines for Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

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