Revenue Cycle Insider

Question: The provider ordered two separate antinuclear antibodies (ANA) lab panels on the same day, coded to 86038. The blood samples for each panel were collected at the same time during the same session. We want to bill 86038 x 2, but that exceeds the payers’ Medically Unlikely Edit (MUE) of “1.” Is there a modifier we can use to override the edit?

AAPC Forum Participant

Answer: Yes, you can append modifier 91 (Repeat clinical laboratory diagnostic tests) to 86038 (Antinuclear antibodies (ANA)) to bill for both tests. However, you don’t say why the provider ordered both tests on the same day, which is key to justifying appending modifier 91 to the second instance of 86038 and getting paid for both tests.

To append the modifier and bill for both tests, your provider must document medical necessity for the provider wanting both tests to be performed on the same date of service (DOS). This could be because the provider needed to see antibody levels at two different times of day, because the provider wanted to see antibody levels before and after treatment, or because the patient exhibited new or changed symptoms between tests that the provider needed to evaluate with a second test.

If the lab ran the test a second time because the blood sample was inadequate or because lab equipment malfunctioned during the test, if the lab needed to confirm the result of the first test, or if the lab repeated the test without provider orders for their own quality control purposes, you should not bill for two tests with modifier 91 appended.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC