FAQs for Medically Unlikely Edits

Q1. Suppose on a lab test, you have a specimen that you test by outpatient observation patient for the hospital sometimes you may do a test in the morning, then in the afternoon and then again after medication has been administered. And when you hit the MUE edit, is a modifier -91 appropriate because you're repeating that lab test on a different specimen? We're trying to figure out what is the true meaning of repeat lab test.

Answer. It actually means that the basis of the modifier is just that it's more than one of that particular test. So, you've already billed that CPT code once in a day. And if you've gotten to the point where it's going to hit the edit, then yes, you could bill that assuming medical necessity is there which in this case it probably is. You could bill the -91 modifier on a separate line to describe that a secondary test or a third test or fourth test or however many it was done to, you know, because it was medical necessity but also that it will allow it because it's on a separate line with that modifier.

The time you wouldn't want to use it is if for chance maybe you did a task and you know, from the machine malfunctioned or for whatever reason it was the lab's fault that the test had to be redone. In that case, you wouldn't want to bill that with the -91. But if the medical necessity exist, yes, that's the perfect of when you would want to use that modifier to indicate that it had been done more than once and that you are using that because that would allow it to be paid.

Q.2 We deal primarily with CPT codes 88300 and higher. So, we haven't been able to find any of them in the table for the MUEs, so we kind of have to guess as what the values are. So can we use a modifier to indicate the same CPT code on multiple lines and then indicate by ICD-9 code that they are separate? So could we, for example, use a -59 modifier and then by the ICD-9 code indicate where the specimen came from? Because what we run into is that we'll get multiple samples which are separately identified, separate reported but then they are denied and we have no way that I can see to indicate to the payer that they are indeed separate specimens.

Answer. Yeah. You know, probably your best bet is exactly what you said, to give them in both the modifier and the ICD-9 code as much information as you can. So, if you use the -59 if that's the most appropriate which probably is for the pathology code and then within the ICD-9 code that you're describing, it's potentially different, and different specimens are being tested for different things—malignancies or whatever it is, whatever you happen to be looking for. So you are using that to describe it is probably your best bet.

And even to use if there's times where an E-code of something like that might be helpful to describe the situation, that might be good and then also obviously the modifier and then making sure that within the pathology report all of that is describe so that if they requested report they can see it all in there as well. It's probably your best bet.

Q.3 We are billing - we have a lot of the 8000 series as well and we are using modifier -59 and -91 but most of our claims are not getting past the RTP phase. So our question is should we be using the -76, -77?

Answer. Probably, not unless it's an actual procedure. These are like the pathology 8000s. Because it's not technically a clinical lab test that's probably not helping you. So the -91 is probably not helping you much. If it's - assuming that it's the actually pathology piece of it and not, you know, the lab piece. You know, probably your best bet is the -59 like I've said and then doing what you can to describe it outside of that and separating them on the separate line.

So have you tried that? If it's, three different 88300s on three different lines with the modifiers attached, is that - you're still getting those RTP'd to you? If the answer to that is yes— unfortunately, that's always my best advice. And the RTP is the medically unreasonable, that's the one that's coming back, the reason code?

Yes! Well, the advice that they give us is to use the -59. The -76, -77s are usually reserved for procedures. So the thing is between the 10000 and the 60000 CPT codes. So is is not advisable using them on the 88000 CPT codes because they're not procedures. However - I'm trying to think, it seems like the -76 actually says procedure or service by the same physician. You could always give it a try. Or at a minimum, talk to your provider relations folks about it or the provider outreach folks at your contractor and say, “You know, would you consider this appropriate?”

Unfortunately, although the process claims nationally, they oftentimes set their own policies so that a modifier that might be accepted in one area isn't in another area. So, you can always double check with them and see. And if - by putting the -59 and different ICD-9 codes if that's not helpful then you can try say the -76 and the different ICD-9 codes for the different things that are done and see if that improves it.