Medicare Compliance & Reimbursement

Plus: Modifiers will help you code for repeat testing, too.

Occasionally, it’s necessary to perform a procedure more than once or require a patient to be tested again if the results are inconclusive. For this kind of coding situation, the use of a modifier can have a profound effect on both your bottom line and compliance — even if the modifier you use is an informational modifier and not a pricing modifier.

In fact, “the non-use, misuse, and overuse of any kind of modifier can have financial implications,” notes Jennifer Swindle, VP of Quality and Service Excellence at Salud Revenue Partners in Lafayette, Indiana.

This is especially true when you are trying to get paid for repeat procedures, services, or tests performed in-house. So, here are some valuable tips and tricks you can use to boost your revenue legitimately and ethically.

Understand How and When to Report Repeat Procedures

“When we report a code with a 76 [Repeat procedure or service by same physician or other qualified health care professional] or 77 [Repeat procedure by another physician or other qualified health care professional], we’re saying [to a payer] ‘we know we already billed this once, we performed this test or service more than once and we want to be paid for both,’” says Swindle. The key, as it is with reporting any procedure or service, either singly or multiple times, is to show medical necessity.

Example: A physician performs a Pap smear and sends it to a pathology lab for histopathological examination. However, the path lab reports that the specimen provided is inadequate, so the provider repeats the Pap smear on the same patient and submits the new specimen back to the lab.

In these situations, “where unsatisfactory screening Pap smear specimens have been collected and conveyed to clinical labs that are unable to interpret the test results, another specimen will have to be collected. When the physician bills for this reconveyance, the physician

should annotate the claim with HCPCS Q0091 [Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory] along with modifier -76,” according to the Medicare Claims Processing Manual, Chapter 18, Section 30.5.E.

Beware of MUEs/MAIs

Though using modifiers 76 or 77 will get you paid for both Pap smears in this instance, you should become familiar with the Medicare concept of Medically Unlikely Edits (MUEs) and their associated MUE Adjudication Indicators (MAIs) when trying to bill for other repeat services.

The MUE for a HCPCS Level II or CPT^® code “is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service,” while an MAI of 1 tells you if an appropriate modifier correctly used for the same CPT^® code on a separate line of the claim will allow you to report “medically necessary units of service in excess of MUE,” according to Medicare Administrative Contractor (MAC) Noridian. Other MAIs will not allow any units for the same service on the same day if the MUE is exceeded (MAI 2) or may allow units when the MUE is exceeded under exceptional circumstances (MAI 3), providing you furnish supporting documentation up front or upon appeal of the denial.

So, for the above example, with an MUE of 1 but an MAI of 3 for Q0091, it is possible to submit a Medicare claim for Q0091 and Q0091-76 or Q0091-77 on the same date of service (DOS) with the right documentation to show medical necessity. But other payers may not reimburse for the same services on the same DOS, and not all services will be subject to the same MUEs and MAIs for Medicare or other payers.

Know the Ins and Outs of Repeat Test Reporting

“If the repeat service happens to be a lab service, you will capture that using modifier 91 [Repeat clinical diagnostic laboratory test]. That says it is medically necessary to do the lab more than one time in one day,” says Swindle.

Example: A provider orders a complete blood count (CBC) for a patient, which is performed in-house. The results come back an hour later, and later in the day the physician needs a second reading to confirm improvement or decline. The practitioner orders the test to be retaken, “so you would report 85025 [Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count] twice, appending modifier 91 on the second CBC along with documentation supporting medical necessity for a second test,” according to Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

Remember: You would only use modifier 91 on the second test, and “only when the results of both labs are needed. If the initial sample is contaminated, or if there is not enough blood or an adequate sample, then it should not be billed as a repeat lab,” Swindle cautions.