Modifier 90

When is modifier 90 used?

Modifier 90 is used to indicate when laboratory procedures are performed by an entity outside of the treating or reporting physician’s office or a qualified healthcare professional’s practice. By adding modifier 90 to the procedure code, healthcare providers can appropriately differentiate between in-house laboratory services and tests conducted by external laboratories. This distinction is crucial for accurate billing and reimbursement processes.

When healthcare providers send laboratory work to external facilities for testing, modifier 90 ensures transparency in coding and billing. It informs payers that the laboratory service was outsourced, helping to prevent potential claim denials or audits due to incorrect billing information. Additionally, using modifier 90 supports compliance with billing regulations and guidelines, promoting accurate documentation of the services provided to patients.

Key guidelines for modifier 90

Modifier 90, “Reference (outside) laboratory,” is used when laboratory procedures are conducted by a laboratory or entity other than the treating or reporting physician or qualified healthcare professional. By appending modifier 90 to the procedure code, it indicates that the service was performed outside of the provider’s office or immediate care setting. This modifier is crucial for accurately reflecting the source of the laboratory procedure and ensuring proper reimbursement.

According to CMS guidelines, when a laboratory test is referred to an external facility for analysis, modifier 90 should be included with the respective CPT or HCPCS code on the claim form. This helps in transparently distinguishing between services physically performed by the treating physician and those outsourced to a separate laboratory. Such clarity in billing is essential for compliance with regulatory requirements and for ensuring accurate processing and payment of claims.

Key guidelines for Modifier 90 include:

1. Modifier 90 is used to indicate that laboratory testing was performed by a laboratory outside of the physician’s office or facility.
2. The reference (outside) laboratory must be a legitimate, independent laboratory that meets all necessary regulatory requirements and follows appropriate testing methodologies.
3.  It is essential to specify the actual code of the laboratory test along with Modifier 90 to indicate that the testing was outsourced.
4. Make sure that the documentation clearly shows the need for the laboratory testing to be done at an outside facility.
5. Modifier 90 should not be used when the laboratory tests are performed in-house or within the same facility.

Healthcare providers need to be diligent in applying modifier 90 appropriately to avoid claim denials and billing discrepancies.

Examples of modifier 90

Here are some examples with scenarios to illustrate the use of Modifier 90:

1. Scenario: A patient visits their primary care physician for routine blood work. The physician collects the samples and sends them to an independent lab for testing. The lab processes the samples and generates the results. In this scenario, Modifier 90 would be appended to the laboratory CPT code to indicate that the testing was performed by an outside laboratory.

2. Scenario: A patient undergoes a complex genetic test that requires specialized equipment and expertise not available at the healthcare facility where the sample was collected. The sample is sent to a reference laboratory known for their proficiency in genetic testing. Modifier 90 would be applied to the CPT code for the genetic test to signify that it was conducted by an outside laboratory.

3. Scenario: A patient receives cancer treatment at a hospital that does not have an in-house facility to conduct tumor marker testing. The hospital sends the tumor marker samples to a national reference laboratory for analysis. Modifier 90 is used with the relevant CPT code to indicate that the testing was performed by an outside laboratory.

4. Scenario: A patient visits their primary care physician for a routine check-up. The physician orders blood work to be done at a reference laboratory that is not affiliated with their practice. In this case, Modifier 90 would be appended to the laboratory test codes on the claim to indicate that the testing was done by an outside laboratory.

5. Scenario: A patient undergoes a surgical procedure at a hospital. The surgeon orders pathology testing on the surgical specimen, which is sent to an external laboratory for analysis. Modifier 90 would be added to the pathology testing codes on the claim to signify that the testing was conducted by a laboratory outside of the hospital setting.

6. Scenario: A patient sees a specialist for a specific medical condition. The specialist orders genetic testing to be performed by a specialized laboratory that focuses on genetic analysis. In this scenario, Modifier 90 would be used with the genetic testing codes on the claim form to indicate that the testing was conducted by an external laboratory.