Modifier 91

SWsibemom

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I am looking for opinions on how much time should elapse to qualify for modifier 91 for a repeat lab. If there is only a minute or two between the tests, I don’t think it would qualify for 91 because that seems to me to be more of a confirmation rather than a separate reportable test. In a webinar it was suggested that two hours is a good space in time between the tests and having a policy regarding timing is a good idea. What are your thoughts on how much time should be in between the tests to qualify for modifier 91?
 

karamac

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I think the answer depends alot on the type of test that is being run, and the instrument that it is being run on. Documentation by your provider will also be very important.

From AAPC Coder and CPT 2019:

For 91-Repeat clinical diagnostic laboratory test-- In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results.
Do not use modifier 91 for tests that the provider repeated to confirm initial results because of testing problems with specimens or equipment, or for any reason when a normal one time result is all that is needed.
Do not use modifier 91 with codes that describe a series of test results, such as glucose tolerance or evocative suppression tests.


This is a problem area for many laboratories-- (1)important to remember that you are collecting a second and/or subsequent sample from the patient you are not just re-running the same specimen a second time. No second specimen- no 91 modifier. (2) The provider also then has to document the use of results from the first test, use them in the treatment of the patient and then re-order a second specimen drawn or collected and run on the instrument. (3) Laboratory instrumentation vary in their ability to run results. AAPC coder provides a good example around glucose testing in a patient who is hypoglycemic- patient is testing is found to be hypoglycemic, is given supplements and re-tested 30 minutes later. Another example where one or two minutes is NOT enough time, would be definitive or even presumptive toxicology testing because the instrument cycle can be an hour or more.

This is modifier is also an area of increasing scrutiny by payers ...

Hope this helps!!
 

danachock

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Hi SWsibemom,
Unless you may have another scenario, I think I may know what your issue is.
Patient arrives at your facility and has blood drawn (many vials) and its resulted. Reviewing the laboratory tests for that DOS it is revealed that the patient came in and had for example a CMP (comp met panel) ordered by provider A that they just saw that day. However there is an outstanding laboratory test by provider B from 3 months ago for exact same lab - CMP (comp met panel) that was also drawn with the other labs from provider A and now there are two charges simply like 2 minutes apart. Is it appropriate to bill both of these charges? At the facility I work for - the answer is absolutely no.
You would simply bill this once. I know from NCCI policy that performing a laboratory test a second time without having medical necessity would be wrong.
Unless you have another scenario where there would be a laboratory test done only minutes apart??? That would be my suggestion.
I have plenty of tests that are done peak and trough and those that are done prior to testing, 30 minutes into testing, 60 minutes, and again at 90 minutes that we bill the subsequent charges with modifier 59 or XE (depending on insurance) with procedure description of time drawn and lab performed.
Thanks for listening,
Dana Chock, RHIT, CPC, CANPC, CHONC, CPMA, CPB
Pathology Coder & Coding Analyst
 

SWsibemom

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Thank you for the replies. We also do not bill when two different providers request the same test and are resulted a few minutes apart. It was suggested in the webinar to set a standard as to what is acceptable for time between tests and was told 2 hours is her threshold because -91 is under scrutiny. I can see the peek and trough example Dana gave would be a consideration as well. I had never thought of a specific time threshold between tests before because I always thought a different sample would qualify for -91 except for when two providers have ordered the same test and are resulted minutes apart and confirmation testing. There may be other examples, but those are the two we deal with the most. Thanks again for your replies.
 
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