Pulmonology Coding Alert

Remember that repeat lab services have their own modifier.

It’s a common occurrence: Your provider performs the same service for the same patient more than once on a single date. If you report the corresponding CPT^® codes on separate lines of your claim form without a modifier appended, you’re likely to get a denial for submitting a duplicate service. Your best bet? Adding the appropriate modifier to your code.

If your head spins when trying to pinpoint the right modifier to use for repeat services, check out five quick facts that can help you iron out the details.

1. Get the Definitions of Your 3 Main Options

Before you can differentiate one modifier from another, get to know the three main options to consider:

• 76 (Repeat procedure or service by same physician or other qualified health care professional)
• 77 (Repeat procedure or service by another physician or other qualified health care professional)
• 91 (Repeat clinical diagnostic laboratory test)

Once you have these descriptors in front of you, it’s time to move on to the best ways to tell them apart.

2. Identify the Provider Who Performed the Service

The difference between modifier 76 and 77 is that you use modifier 76 when only one physician performs the procedures or services, and you use 77 when there is a second physician performing the subsequent procedure or service.

When you find that your physician repeats a procedure on the same date, look to see if there was a second physician

before you make your modifier decision. When there are two physicians, they need to be in the same practice or group for the service to qualify as a repeat. If the two physicians are in different groups, you can simply report the code for the second physician’s service with no modifier.

3. Single Provider? Look to 76

Modifier 76 is your go-to choice when the same provider performs both procedures.

How you’ll list the codes on your claim form may depend on your payer.

For instance, according to a January 2024 Fact Sheet from Part B Medicare Administrative Contractor (MAC) Novitas Solutions, you should append modifier 76 to the code, along with the number of repeated services, on one claim line. “Do not report modifier 76 on multiple claim lines to avoid duplicate claim line denials,” Novitas says. “Bill all services performed on one day on the same claim, to avoid duplicate claim denials. Part B MAC >NGS Medicare also states, “The procedure code is listed once, and then listed again with modifier 76 added (two line items.) The second line item will have the appropriate quantity billed amount.”

However, when you’re billing more than two procedures, such as three instances of the same procedure, you’ll enter the applicable CPT^® code on line 1 without a modifier plus the CPT^® code on line 2 appended with modifier 76 and a number 2 in the units field.

Example: A patient presents to your office with a cough and wheezing. The pulmonologist evaluates the patient and confirms the patient is experiencing an asthma exacerbation. The physician then administers a breathing treatment. After observation in the office for 30 minutes, the patient’s wheezing improved slightly and the provider attempts a second breathing treatment before deciding if the patient requires more intensive treatment in the emergency department (ED).

You would report 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) for the initial breathing treatment and 94640-76 for the second breathing treatment.

4. Different Provider Warrants 77

You’ll use modifier 77 when one provider in your practice performs the first service and a separate provider performs the second. If you submit identical, duplicate services for the same date of service “by another performing provider with the same specialty within the billing group without the use of any modifier,” you’ll find your claim denied, according to February 2024 guidance from Blue Cross Blue Shield of North Dakota. This guidance seems to propose that both services can be reported on the same claim as long as both providers are in the same group and the same specialty. Two claims are required when providers are part of different groups and/or specialties.

Example: Suppose the patient from our example above presents to your office in the morning with a cough and wheezing, and Dr. Smith administers the breathing treatment. Thirty minutes later, Dr. Jones (another pulmonologist) administers the second breathing treatment because Dr. Smith had to leave for the day.

You would report 94640 for Dr. Smith’s time with the patient, and 94640-77 for Dr. Jones’ work with the patient. Novitas notes that you should report each procedure on a single line of separate claims — once alone (94640 with no modifiers) by the first provider and once with modifier 77 appended by the second provider who repeated the service. “Do not use the units field on either claim to indicate the procedure was performed more than once on the same day,” Novitas adds.

5. Eye Modifier 91 for Repeat Lab Tests

When it comes to laboratory tests, you should avoid modifiers 76 and 77 in most situations. Most payers began denying lab services with these modifiers appended about 15 years ago. Instead, you’ll use modifier 91 for your repeat lab tests, with one caveat.

Important: “Modifier 91 is used to report repeat laboratory tests on the same date of service to obtain multiple test results,” Blue Cross Blue Shield of North Dakota says. “Modifier 91 should not be used when tests are repeated to confirm initial test results due to testing problems with equipment or specimens or with codes that describe a series of test results, such as glucose tolerance or evocative suppression tests.”

Remember: If you’re reporting a code for a test performed in a Clinical Laboratory Improvement Amendments- (CLIA-) waived lab, in most cases, must append modifier QW (CLIA waived test) to your CPT^® code. Only CLIA-waived tests can be performed in a physician’s office. However, you should never assume that a particular service is on the CLIA-waived list — always check first. The Centers for Medicare & Medicaid Services (CMS) updates the list of CLIA-waived test codes each quarter.

Example: Suppose the physician performs a nasal swab for qualitative detection of influenza type A antigen. The physician also performs a nasal swab for qualitative detection of influenza type B antigen.

In this situation, you’d report 87804 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza) appended with modifier QW once on the first claim line, followed by 87804-QW on the next claim line. You’ll want to review your individual payer preferences to confirm the use of modifier 91 with the second 87804 use.

Example 2: Suppose the pulmonologist performs a nasal swab for a patient experiencing runny nose, sore throat, and a cough. The specimen is to identify a possible respiratory syncytial virus (RSV) infection. The lab tech accidentally threw away the sample, so the ordering provider never receives the test results. The pulmonologist then collects another sample from the patient and runs the test again.

In this situation, you cannot report 87807 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus) with modifier 91 for the subsequent test because it was repeated due to user error. You’d only report 87807-QW once in this example.

Beware: Payers may have their own individual policies on how to use modifiers 76, 77, and 91 so be sure to contact your payer for clarification before you start using them.

Torrey Kim, Contributing Writer, Raleigh, N.C.