Description Repeat clinical diagnostic laboratory test performed on the same day. (Separate Specimens Taken in Separate Encounters)
Required for Claims Critical Access Hospitals (CAHs); Outpatient Prospective Payment System (OPPS) Hospitals, End Stage Renal Disease (ESRD) Facilities; Skilled Nursing Facilities (SNFs)
Type of Bill: 12X, 13X, 14X, 22X, 23X, 72X, 85X
Coding Guidelines Applies to laboratory tests paid under the clinical diagnostic laboratory fee schedule.
General Guidelines
A. Modifier –91 is used to indicate that a test was performed more than once on the same day for the same patient, only when it is necessary to obtain multiple results in the course of treatment.
B. Modifier –91 MAY NOT be used:
• When tests are re-run to confirm initial results;
• Due to testing problems with specimens or equipment; OR
• For any other reason when a normal one-time, reportable result is all that is required.
C. Modifier –91 MAY NOT be used when there are standard HCPCS/CPT codes available that describe the series of results (e.g. glucose tolerance tests, evocative/suppression testing, etc.)
D. If an ordering physician requests a laboratory test that requires that several of the same services (same CPT codes) be performed for the same beneficiary on the same day, the laboratory should use modifier –91 to indicate that multiple clinical diagnostic laboratory tests were done on the same day. An example would be a repeated test later in the day to followup on an abnormal finding on the same test result performed earlier in the day.
Billing and Coding Guidelines for odifier “-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.
When billing for repeat laboratory procedures, providers should bill all of the units on one line item with modifier -91. For all other services being billed with modifier -76 (or -77) to indicate the repeat procedures, providers should bill an initial line item with no modifier along with one unit, followed by a second line item date of service with the -76 (or -77) modifier and all of the repeat units.
Appropriate Use of Modifier 91
Modifier 91 is used to report repeat laboratory tests or studies performed on the same day on the same patient. This modifier is added only when additional test results are to be obtained subsequent to the initial administration or performance of the test(s) on the same day. It is not used when laboratory tests or studies are simply rerun because of specimen or equipment error or malfunction. Nor is it to be used when a test is repeated to confirm initial test results. Further, based on the definition of modifier 91, it should not be reported when the basic procedure code(s) indicate that a series of tests are to be obtained. CPT codes for use with modifier 91 are in the laboratory code range 80047-89398. Services with multiple units should be billed on one line with the appropriate units and modifier indicated.
Appropriate Use of Modifier 76 and 91
On April 18, 2011 Blue Cross and Blue Shield of Oklahoma (BCBSOK) implemented ClaimsXten™, a code auditing tool developed by McKesson Information Solutions, Inc. One feature of this tool is the Modifier-to-Procedure Validation editing. Since the implementation of ClaimsXten, BCBSOK has noticed an increase in the use and potential misuse of modifiers 76 and 91.
Modifier 76 is reported to communicate that a service or procedure was repeated by the same practitioner subsequent to the original procedure or service. Without the modifier, subsequent reporting of the same procedure by the same provider could mistakenly be interpreted as being a duplicate. This modifier may be used whenever the circumstances warrant the repeat procedure. Based on the definition of modifier 76, it would be inappropriate to append modifier 76 to clinical laboratory tests on the same day. CPT codes for use with modifier 76 are 10021-69990, 70010-79999, 90281-99199, and 99500-99607, when appropriate.
Modifier 91 is used to report repeat laboratory tests or studies performed on the same day on the same patient. This modifier is added only when additional test results are to be obtained subsequent to the initial administration or performance of the test(s) on the same day. It is not used when laboratory tests or studies are simply rerun because of specimen or equipment error or malfunction. Nor is it to be used when a test is repeated to confirm initial test results. Further, based on the definition of modifier 91, it should not be reported when the basic procedure code(s) indicate that a series of tests are to be obtained. CPT codes for use with modifier 91 are in the laboratory code range 80047-89398.
Clear Claim Connection™ (C3) will continue to be the provider resource that allows disclosure of claim auditing rules and clinical rationale to the BCBSOK independently contracted provider network. C3 is a free online tool available to providers who are registered with Availity®. After logging on to the Availity provider portal , look for Claims Management/Research Procedure Code Edit. If you are not currently a registered user, visit Availity to sign up.
Policy and Definition of Modifier 91
HealthKeepers, Inc. allows reimbursement of claims for repeat clinical diagnostic laboratory tests appended with Modifier 91, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.
Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate of the clinical diagnostic laboratory test billed with Modifier 91.
Medical documentation may be requested to support the use of Modifier 91. Failure to use the modifier appropriately may result in denial of the repeated laboratory test as a duplicate service.
History
* HealthKeepers, Inc. biennial review 10/31/14: History and policy template updated
* Initial HealthKeepers, Inc. review approved and effective 11/01/13 References and Research Materials
This policy has been developed through consideration of the following:
* CMS
* State Medicaid
* HealthKeepers, Inc. contract(s) with the Virginia Department of Medical Assistance Services
* Optum Learning: Understanding Modifiers, 2014 edition
* Optum Learning: Understanding Modifiers, 2014 Edition
* The Essential RBRVS, 2014 Edition
Definitions
* Modifier 91: Used to indicate a clinical diagnostic laboratory test was repeated on the same day for the same member to obtain multiple test results. Modifier 91 may not be used in the following situations:
o To repeat a test to confirm initial results, or because there was a problem with the specimen or equipment when performing the initial test; or
o When other code(s) describe a series of test results.
* General Reimbursement Policy Definitions
Modifier “-91” Usage with example
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.
91 Repeat Clinical Diagnostic Laboratory Test: In the same 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. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the CPT modifi er 91.
Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other codes describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory tests performed more than once on the same day for the same patient.
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