Wiki Help with Modifier -90

[nca1006]

Okay. I know that many states are different so while reading/responding, keep in mind I am working in Alabama.

So, my office manager tells me I need to bill 36415 with a -90 to all insurances except Medicare, UHC Medicare plans, and Humana. My office has an in house lab where we draw and perform some labs. CBC, A1c, CMP and Lipid are all done in our lab when ordered. Other tests are sent out. We have an employee of our partnered lab that draws in the morning, and our lab tech draws in the afternoon. Here comes the main question..

If the following CPT's are done/ordered, and the patient has BCBSAL insurance, what is the proper way to bill?



99214
36415-drawn by partner lab employee
80053-performed in house
80061-performed in house
83036-performed in house
83735-sent out to partner lab

I have been told this is how I am supposed to bill it by my office manager:

99214
80053
80061
83036

Notice I did not bill for the 36415 because it was not drawn by our employee. It was drawn by the partner labs employee. Also, I did not bill 83735 because it is not performed in our office. It is sent to the reference lab.

If it was drawn by our lab tech, I have been told to bill as follows:

99214
36415-90
80053
80061
83036

Notice I still did not bill for the 83735 because it was sent to the reference lab.

Everything I can find to read on this says that this is wrong. But I need further clarification and documentation in order to make the office manager understand.

Please help!!

 

[CodingKing]

I work for a multi state commercial payer and it seems only Alabama offices are sending modifier 90 on 36415. We follow CMS which states modifier 90 is inappropriate with 36415 as it cannot be referenced out to another lab.

Here is Primera Blue Cross policy for example they wont accept modifier 90 on any code

https://www.premera.com/paymentpolicies/cmi_051731.pdf

Use of modifier 90 indicates that a laboratory test was performed by a party other than the treating or reporting physician or other qualified health care professional.

The Plan will no longer reimburse laboratory tests billed by a party other than the performing laboratory nor tests submitted with modifier 90 appended to the laboratory test procedure code.

Laboratory services must be submitted directly to the Plan by the provider who actually performed the laboratory test. Reimbursement will be made directly to the laboratory that performed the service(s), for those laboratory services covered by the member’s benefits.