Clinics and Other Outpatient Facility Services Handbook - TMHP

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 - JANUARY 2013
Modifier 91 is used to indicate that a test was performed more than once on the same day for the same
client only when it is necessary to obtain multiple results in the course of the treatment. This modifier
may not be used to indicate any of the following:
• When tests are rerun to confirm initial results
• Testing problems with specimens or equipment
• When a normal one-time, reportable result is all that is required
• When there are standard Healthcare Common Procedure Coding System (HCPCS) codes available
that describe the series of results (e.g., glucose tolerance tests, evocative/suppression testing, etc.).
Modifier 91 may only be used for laboratory tests paid under the clinical diagnostic laboratory fee
schedule.
Per Dialysis
Procedure Codes
85014 85018 85345 85347
Per Week
Procedure Codes
82565 84520 85610
Per Month
Procedure Codes
82040 82310 82374 82435 83615 84075 84100 84132 84155 84450
85025 85027
The routine tests listed in the previous tables are frequently performed as an automated battery of tests
such as the sequential multi-channel analysis with computer (SMAC)-12 (chemistry panels). These tests
are considered routine and are included in the charge for dialysis, unless there is an additional diagnosis
to document medical necessity for performing the tests in excess of the recommended frequencies.
6.2.9.2 In-Facility Dialysis—Nonroutine Laboratory
The following procedure codes are considered necessary, nonroutine tests. They must be submitted
separately from the dialysis charge when performed in the renal dialysis facility or by an outside
laboratory that bills the facility for laboratory services. All nonroutine laboratory and radiology tests
beyond the recommended frequencies below must be medically necessary.
If additional in-facility laboratory testing is medically necessary beyond the nonroutine frequencies
identified below, providers must submit the claim with modifier 91 to indicate the billed laboratory
procedure is medically necessary. The billing provider must also submit documentation supporting the
medical necessity with the claim and maintain the documentation in the client’s medical record.
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