90 - JE Part B

Reference (Outside) Laboratory

Instructions

Sometimes a clinical diagnostic independent lab, place of service (POS) 81, refers a specimen to another lab for testing, where a modifier 90 is appended.

Correct Use

• Outside laboratory performs procedure, unrelated to treating/reporting physician
  • In most cases, lab furnishing the service would bill the claim
• Possible for one lab to bill service performed by another lab
  • Referring = referring specimen to another laboratory for testing
  • Reference = lab that receives specimen from another lab and performs one or more tests on such specimen
• Must append modifier 90 to referred laboratory test code
  • Item 20 mark "Yes" = outside lab
  • Purchase price must be reflected under charges
  • Complete item 32 with NPI, name and address where performed
• Appropriate modifier 90 claims include two different Clinical Lab Improvement Amendment (CLIA) numbers
  • Reflect billing provider information
  • Laboratory where services were performed (reference lab)
• Bill claims with modifier 90 and without modifier 90 separately
• If no purchased services, leave item 20 blank

Inappropriate Use

• Do not report modifier 90 with anatomic pathology and lab services
• Do not append modifier 90 for drawing fee (36415)
  • Cannot be referenced out to another lab

Claim Coding Example

Resource

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 40