Modifier 90 reference lab
CPT Modifier 90 Reference Lab
In medical billing, Modifier 90 holds significance when laboratory tests are conducted by a healthcare provider other than the attending physician. Specifically relevant for Medicare billing, this modifier is utilized by independent clinical laboratories when referring tests to an external reference lab for comprehensive analysis. Understanding and correctly applying Modifier 90 ensures accurate documentation and streamlined processing of laboratory procedures conducted outside the immediate care setting.
Outside Lab Reference
In the realm of medical billing, while laboratory tests are carried out by a healthcare provider aside from the attending or reporting physician, a particular modifier, called CPT Modifier 90 Reference Lab, is utilized to denote this situation along the standard procedure code. In the context of Medicare billing, CPT Modifier 90 Reference Lab is employed by way of independent medical laboratories after they refer exams to an external reference lab for comprehensive analysis. This modifier plays a crucial position in accurately documenting and processing laboratory methods carried out out of doors the immediately care putting.
CPT Modifier 90 Reference Lab serves as a critical indicator when a physician or clinic orders laboratory tests for a patient, which are then conducted by an external or reference laboratory. It signifies that although the physician reports the test’s performance, the actual testing service is provided by a separate laboratory entity.
This CPT Modifier 90 Reference Lab is essential in situations where laboratory procedures are carried out by a party other than the treating or reporting physician, with the laboratory subsequently billing the physician for the service rendered. For instance, when a physician orders a Complete Blood Count (CBC), draws the blood in-office, and forwards the specimen to an external laboratory for analysis, Modifier 90 is applied to denote the utilization of outside reference laboratory services during billing:
- CPT Modifier 90 Reference Lab does not bypass clinical edits, subsets, bundling, etc..
- CPT codes 99000 and 99001 (handling fees) are not eligible for separate reimbursement when modifier 90 is used.
- If a combination of blood or serum lab procedures is conducted by the provider and others are sent to an outside lab with CPT Modifier 90 Reference Lab, CPT 36415 is not eligible for separate reimbursement
Correct Use
- The correct use of CPT Modifier 90 Reference Lab occurs when an outside laboratory performs a procedure that is unrelated to the treating or reporting physician.
- Typically, the laboratory providing the service would submit the claim for reimbursement.
2. It’s possible for one laboratory to bill for services performed by another laboratory, indicating a collaborative arrangement.
- “Referring” denotes the act of sending a specimen to another laboratory for testing.
- “Reference” refers to the laboratory that receives a specimen from another lab and conducts one or more tests on it
3. Modifier 90 must be added to the referred laboratory test code.
- Mark “Yes” in Item 20 if the service was conducted at an outside lab.
- The purchase price should be accurately represented under charges.
- Item 32 must be completed with the NPI, name, and address of where the service was performed.
4. Proper Modifier 90 claims should include two distinct Clinical Lab Improvement Amendment (CLIA) numbers.
- Ensure the billing provider information is accurately reflected.
- Specify the laboratory where the services were performed, known as the reference lab.
5. Separately bill claims with and without Modifier 90.
6. If there are no purchased services, leave Item 20 blank.
Incorrect Usage
1. Separately bill claims with and without Modifier 90.
2. If there are no purchased services, leave Item 20 blank.
- It’s not permissible to refer services out to another laboratory.
Conclusion
In conclusion, understanding the correct application of Modifier 90 is essential in medical billing to accurately reflect laboratory services performed outside the immediate care setting. By adhering to guidelines and avoiding inappropriate use, healthcare providers can ensure proper reimbursement and maintain compliance with billing regulations.
At AcuteMD, we specialize in medical billing solutions, providing comprehensive support to healthcare professionals to navigate complex coding requirements and optimize revenue streams. Contact us today to learn more about how AcuteMD can streamline your billing processes and maximize financial efficiency in your practice.
