Daryl Posted Mon 06th of June, 2016 12:52:01 PM
I'm not sure if this post needs to be broken into a few different questions, but you can let me know.
The overarching scenario I am asking on is for a centralized lab receiving patient samples and billing patient insurance directly for tests run. My questions are as follows:
-If multiple genes are evaluated on a single date of service using Tier 2 codes (81400 thru 81408) and 81479, what are the MUEs for each of these codes? Does this differ whether the multiple genes are tested separately vs. being tested together on one panel?
-What if two tests using similar MoPath Tier 2 CPTs that together exceed the MUE threshold are tested with the same date of service? For example, if a lab runs two tests, both with 3 iterations of 81405 how would that be handled to ensure payment?
-What modifiers can be used for Tier 2 MoPath codes 81400 - 81408, and 81479 for these scenarios, and when are they used? For example, there have been 59 modifiers, 91 modifiers and 25 modifiers that have been described, but when is each type used?
-Do any of these scenarios change if patient samples are sent to us from another reference lab to run, or if any samples from our lab are sent to another centralized lab to run?
-Last question: Is there any source describing the situation for MUEs and modifiers for MoPath Tier 2 codes for private payers (not Medicare, Medicaid or TriCare)? If so, where can I find it? If not, what is known about the private payer situation regarding MUEs and modifiers for these codes?
SuperCoder Answered Tue 07th of June, 2016 01:37:42 AM
An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. You can download MUEs from cms website below is the link.
The Tier 2 codes are analyte specific and method independent and Report code 81479, Unlisted molecular pathology procedure, once per specimen and date of service for all unlisted analytes tested if an analyte is not specifically included in Tier 1 or Tier 2. If multiple analytes not specifically identified in Tier 1 or Tier 2 are performed for a particular patient on a single date of service, only one unit of 81479 would be appropriate.
Although some third-party payers have suggested that modifier 91, Repeat Clinical Diagnostic Laboratory Test can be appended to every laboratory code that is reported more than one time on the same date of service, per the CPT coding guidelines; this is not the appropriate method of reporting modifier 91.
Modifier 91 indicates: 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 the modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equip-ment; 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 (eg, 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.
Modifier 91 is intended to identify a laboratory test that is performed more than once on the same day for the same patient, when it is necessary to obtain subsequent (multiple) results in the course of the treatment. Modifier 91 is not intended to be used when tests are rerun to confirm initial results due to testing problems with the specimen(s) or equipment, or for any other reason when a normal, one-time reportable result is all that is re-quired. In addition, modifier 91 is not intended for use when there are CPT codes available to describe the series of results (eg, glucose tolerance tests, evocative/suppression testing, etc).
In certain instances, it may be appropriate to report multiple units of a laboratory test; however, modifier 91 is not appropriate because the service/procedure was not repeated as stated in the definition of modifier 91. For labo-ratory reporting purposes, modifier 59, Distinct Procedural Service, is used. For example, to report procedures that are distinct or independent, such as performing the same procedure (which uses the same procedure code) for testing of a different specimen (eg, aerobic culture of two independent wound site specimens). As a matter of differentiation, modifier 91 is used, when in the course of treating a patient, it is necessary to repeat the same laboratory test on the same day to obtain subsequent test results. An example is repeated blood testing for the same patient, using the same CPT code, performed at different intervals during the same day (eg, initial and three subsequent blood potassium levels).
Daryl Posted Thu 07th of July, 2016 11:19:27 AM
Regarding MUEs for molecular pathology tier 2 codes (81400-81408) there are those that apply to "practitioners" and those that apply to "hospital outpatient". For a standalone reference lab, which one would apply?
SuperCoder Answered Fri 08th of July, 2016 04:44:53 AM
If the RHC/FQHC is provider-based, payment for lab tests is to the base
provider (i.e., hospital). If the RHC/FQHC is independent or free
standing, payment for lab tests is made to the practitioner (physician) via the clinical lab fee schedule.