Outpatient Facility Coding Alert

Published on Fri Feb 20, 2015 PDF

Question: According to our billing department, Coventry Insurance requested modifier 59 on the second flu screening test. Usually we code it by appending modifier 91 on the second screening line, and we have been getting paid. We believe modifier 59 is for a distinct procedural service not a repeat clinical diagnostic laboratory test like modifier 91. Could you please clarify?

New Jersey Subscriber

Answer: You are correct in your understanding of the modifiers. You would use modifier 59 (Distinct procedural service) when separate results are reported for different species or strains that are described by the same code.

Payer guidelines may vary from state to state. It would be best to contact Coventry and verify whether modifier 91 (Repeat clinical diagnostic laboratory test) is appropriate.

Refresher: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. For 2015, also refer to the new X{EPSU} modifiers for more specificity in lieu of modifier 59 when appropriate.

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. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91.

Note: Do not use modifier 91 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 code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.