Pathology/Lab Coding Alert

Don’t rely on definitions alone.

You can parse the CPT® modifier descriptors and scratch your head all you want, but you’ll never avoid denials for multiple units of lab or pathology services if you ignore payer instruction.

If your pathologist or lab performs multiple units of a single CPT® code for the same patient on the same day, we have three great tips for you to make sure you get paid for your services.

Tip 1: Know Your Options

Depending on whom you ask and what CPT® code you’re using, several choices exist for reporting multiple units of a specific code for the same patient on the same day. The options are as follows:

• Use modifier 59 (Distinct procedural service)
• Use modifier 76 (Repeat procedure or service by same physician or other qualified health care professional)
• Use modifier 91 (Repeat clinical diagnostic laboratory test)
• List a number in the claim’s quantity field or use multiple claim lines  
• Use modifier 51 (Multiple procedures)
• Use modifier 50 (Bilateral procedure).

Modifier 50 would never make sense for clinical lab tests and would only be appropriate in limited surgical pathology circumstances, such as bilateral iliac crest bone marrow biopsy exam. 

Modifier 51 is appropriate when the same entity provides multiple non-E/M procedures in the same session, according to CPT® instruction. Although this may make sense for situations such as when a pathologist examines multiple specimens at the same surgical pathology level, you’ll find very few payers that accept modifier 51 for this scenario.

There’s more: If you’re wondering about the first four options in the preceding list, move on to tips 2 and 3 to get more guidance for your claims.

Tip 2: Don’t Make 59 Your Go-To Choice

No matter how you’ve used modifier 59 in the past, you might need to rethink your policies. Medicare has virtually commandeered the use of this modifier for overriding Correct Coding Initiative (CCI) edits.

Beware claims edits: Last year, several Part B Medicare Administrative Contractors such as Cahaba and Noridian set up claims processing edits to deny multiple units of a single code when listed with modifier 59. These edits effectively put a halt to using modifier 59 for “repeat” procedures. 

For instance: Your pathologist might examine three distinct skin lesions, justifying three units of 88305 (Level IV - Surgical pathology, gross and microscopic examination, …Skin, other than cyst/tag/debridement/plastic repair…). Some coders are used to listing each 88305 on a separate claim line with modifier 59 on the second and subsequent lines. But that would lead to a denial for a payer with this new claims edit, so you’ll need to streamline how you use modifier 59 for those payers.

Do this: Continue to use modifier 59 to override CCI edits, when appropriate. Remember that if a CCI edit pair shows a modifier indicator of “1,” you may use a modifier to override the edit, under certain circumstances; but when the edit pair shows modifier indicator of “0,” you can never use a modifier, according to Frank Cohen, principal and senior analyst for The Frank Cohen Group in Florida.

And although modifier 59 has been a go-to choice to bypass CCI edits, other options are available, reiterates Laureen Jandroep, CPC, CPC-I, CMSCS, CHCI, senior instructor at CodingCertification.org in Oceanville, NJ. For instance, modifier 50 or anatomic modifiers may be appropriate in some circumstances of surgical pathology procedures.

Position matters: When overriding CCI edits, you’re supposed to append modifier 59 to the column 2 code. But the Office of Inspector General (OIG) has found that 11 percent of claims listed modifier 59 with the primary (column 1) code, while 13 percent listed modifier 59 on both codes. The OIG has urged Medicare payers to deny these claims, but technical restrictions have kept them from putting such an edit in place. 

Action: “If you notice that you have put modifier 59 on the wrong code, resubmit the claim,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. In the event of an audit, payers should look positively on your proactive stance, she adds. 

Tip 3: Follow Payer Rules

If some payers are giving 59 the boot for reporting multiple units of a single CPT® code for the same patient on the same day, what’s a coder to do?

Do what your payer asks. Here are some examples of how payers may instruct you to handle the multiple-unit situation.

For multiple units of a clinical laboratory test, such as 82803 (Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 [including calculated O2 saturation]), many payers instruct you to report the subsequent unit of a medically necessary clinical lab test with modifier 91. Payers generally limit modifier 91 to use with tests paid on the clinical diagnostic laboratory fee schedule (CLFS) rather than the physician fee schedule (PFS). But sometimes Medicare Part A payers request modifier 91 for any repeat 80000 level code reported by a hospital lab.

For multiple units of service paid on the PFS, more Medicare payers are beginning to ask that you list the subsequent code with modifier 76, especially as they begin to focus modifier 59 for CCI use. 

However, some contractors don’t want you to use a modifier at all to denote multiple units of a single CPT® code for the same patient on the same day. Instead, they want you to list the number of units in the quantity field of the claim form.

Bottom line: “No matter how CPT® intended the modifiers to be used or how we were taught or interpret them, we need to use the modifier that the payer wants, and how they interpret the rules,” says Jonathan Rubenstein, MD, director of coding and physician compliance for a physician practice in Baltimore. “If a payer prefers the 76 modifier based upon their interpretation and their publications, then use that modifier if it is appropriate and supported by correct documentation,” he says.