Mind your modifiers: Modifier 91 – Find solution to denials triggered by lab service modifier
Published: Dec 1, 2014
Publisher: Anesthesia and Pain Coder's Pink Sheet
A sharp increase in utilization, revenue and denials for claims associated with the modifier for repeat lab tests could combine to expose anesthesia and pain management practices to scrutiny, overpayment demands and fraud allegations.
Modifier
91 (Repeat clinical laboratory diagnostic tests) should be used only in certain, limited instances. However, an
Anesthesia & Pain Coder’s Pink Sheet analysis of Medicare’s utilization data suggests that doctors need to proceed with caution when they use the modifier — claims billed with it have a 22% denial rate.
To curb denials and reduce your audit exposure, remind staff of the rules for modifier 91. “There are times when it is necessary to perform the same test during the same calendar day,” says Joan Gilhooly, MBA, CPC, CPCO, president, Medical Business Resources, LLC, Cincinnati.
For example:
- A patient who is severely anemic needs a transfusion. The doctor orders a complete blood count or CBC (85025) at the beginning of the treatment. Some number of hours later, the doctor orders a second CBC to see whether the transfusion has helped. The coder would append modifier 91 to the second CBC
- A patient receives a basic metabolic panel (80047) in the morning and all of his levels are normal. In the afternoon, he has symptoms of hypoglycemia and the doctor orders a glucose test (82947). Because blood glucose is part of the basic panel, the coder has to append modifier 91 to the glucose test.
You’re repeating the test or some component of the test because you need to see how the patient is doing, Gilhooly says. You append modifier 91 to tell the payer the subsequent tests are necessary to treat the patient.
Guidance from the CPT manual, Medicare and private payers all emphasize you should not use modifier 91 for the following circumstances:
- To rerun a laboratory test to confirm results
- When there were testing problems for the specimen.
- When there were testing problems with the equipment.
- When another procedure code describes a series of tests.
- When the procedure code describes a series of tests.
- For any reason when a normal, one-time result is required.
Gilhooly believes that confusion over when to use modifier 91 and when to use modifier 59 (Distinct procedural service) is another contributing factor. For example, a provider who tests three different analytes that don’t have their own codes may report a code with modifier 91. That would not be correct. They should report 82542 once and 82542-59 twice, Gilhooly says.
Modifier 91 indicates you did the same test on the same analyte more than once per day. Modifier 59 indicates you did a completely different service but are using the same code, Gilhooly says.
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