modifier 59 or 91

[kiplynj]

Ive been having an issue with the insurance company Us Department of Labor. They have been paying on some lines on my claims, but denying the lines with a -59 stating the modifier is invalid. (I'm pretty sure they are wanting us to use a -91) Ive been going back and forth with them on this stating that this is correct billing and if we used the -91 it would be incorrect.

The cpt codes we are using that would have a -59 that are being denied are 82542 and 83925.

Thanks
Kip

 

[KathyJohnson]

I must be missing something. You aren't running the same tests again so why the modifier? We don't use a modifier unless we're performing the same test again, or multiple units of the same cpt code.

 

[vazq123]

The 91 modifier should only be used if the exact same testing is being performed on different specimens for medically necessary reasons. It should not be used to indicate multiple units. CPT code 82542 is for unspecified LC/MS testing not elsewhere specified and 83925 is for the Opiate confirmation so if you are billing either of these codes more than once a day I am assuming it is due to different drugs being tested which would make the 91 modifier inappropriate.
If different drugs being tested is the reason for the use of the 59 modifier and you report the 91 modifier on your claims you are indicating to the carrier that the test in question was the same test and that it was separately performed more than once to obtain comparison results.

If a carrier is indicating they will only pay for a 91 modifier the appropriate action would be to appeal with backup documentation showing why the use of the 91 would not be appropriate for your services. This may require taking the appeal to the highest level.

Laboratory billing for DOA are definitely under scrutiny and improper use of either codes or modifiers will result in unwanted audits and/or recoupments, which no one wants.

Bellow is from the CMS claims processing manual on the proper use of the 91 modifier:

C. Modifier ?-91?
Definition - The ?-91? modifier is used to indicate a repeat laboratory procedural service on the same day to obtain subsequent reportable test values. The physician may need to indicate that a lab procedure or service was distinct or separate from other lab services performed on the same day. This may indicate that a repeat clinical diagnostic laboratory test was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain subsequent reportable test values.Rationale - Multiple laboratory services provided to a patient on one day by the same provider may appear to be incorrectly coded, when in fact the services may have been performed as reported. Because these circumstances cannot be easily identified, a modifier ?-91? was established to permit claims of such a nature to bypass correct coding edits. The addition of this modifier to a laboratory procedure code indicates a repeat test or procedure on the same day.
Instruction - The additional or repeat laboratory procedure(s) or service(s) must be identified by adding the modifier ?-91?.
EXAMPLE 1:
When cytopathology codes are billed, the appropriate CPT code to bill is that which describes, to the highest level of specificity, what services were rendered. Accordingly, for a given specimen, only one code from a family of progressive codes (subsequent codes include services described in the previous CPT code, e.g., 88104-88107, 88160-88162) is to be billed. If multiple services on different specimens are billed, the ?-91? modifier should be used to indicate that different levels of service were provided for different specimens. This should be reflected in the cytopathologic reports.
Good Luck.

 

[kiplynj]

the example that AAPC Coder tip gives it that it is payor directed:

Tips

Question: We sometimes receive orders to test for multiple opiates, may be as many as eight. Because the 83925 definition states "opiate(s)," we have a disagreement in our lab about whether we can report multiple units, or just one. We've also heard that there is an MUE for this code. Could you please clarify how we should code these cases?



Answer: You should report 83925 for each opiate test procedure that you perform. If you separately test for eight opiate metabolites, you should report 83925 x 8, or use modifiers 59 (Distinct procedural service) or 91 (Repeat clinical diagnostic laboratory test) for the additional units, as your payer directs.

 

[vazq123]

each opiate test procedure that you perform. If you separately test for eight opiate metabolites

the question is: is each test being performed separately? probably not. most likely if the testing is being performed by LC/MS then there is an aliquot for opiates and possibly opioids resulting in multiple results, this all depends on the methodology being used in the lab they may do more.
The modifier being used must appropriately reflect the services being performed.

You may be able to use and support the use of the 91 for opiates if there is separate testing being performed. If one aliquot is used for testing Codeine /Morphine/6-MAM, then another to test Tramadol then you have separate tests being performed and can argue that if the report supports it, however the intention for the use of the 91 modifier was to allow a provider to receive reimbursement if the same test for the same condition was needing to be repeated within the same day for patient care.
Remember 82925 still has a MUE of 4 so you may still may have to appeal and validate what the medical necessity is for billing 82925 multiple times in a day, regardless.

You originally said you are also billing the 82542, this code unlike the 82925 is unspecified so I am assuming it is being used for confirmations on some of the unlisted classes? If so, it would not be the "same" test for the "same" drug being performed as it is with the 82925. 82542 can be used for confirmations such as THC, Fluoxetine, etc. which would be the same method but not the for the same result, hence the 91 not being appropriate.

Anything you do you must be 100% sure it is appropriate and any documentation you have will stand up and support the services being performed and billed.

If I may ask, is this a small start up lab? Are you trying to set up your coding/billing rules?

 

[KathyJohnson]

Try this link for a good flow chart from Medicare for modifier 59. This is on Florida's Medicare contractors site, First Coast.

http://medicare.fcso.com/wrapped/243924.pdf

here's an article by CMS on it as well.

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf

and
http://medicare.fcso.com/FAQs/Answers/158835.asp

I tried to find articles on modifier 91 but really didn't find anything. The big focus seems to be on 59 as it's quite frequently being used improperly and resulting in millions of dollars in over-payments each year.