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24.2.12.2 Modifier 91
Modifier 91 must be used for clinical diagnostic laboratory tests performed more than one time per day as follows:
• Modifier 91 must not be used when billing the initial procedure. It must be used to indicate the repeated procedure.
•If more than two services are billed on the same day by the same provider regardless of the use of modifier 91, the claim or detail is denied.
•If a repeated procedure performed by the same provider on the same day is billed without modifier 91, it is denied as a duplicate procedure.
•If a claim is denied for a quantity more than two or as a duplicate procedure, the times of these procedures must be documented on the appeal.
•Modifier 91 is not required and must not be used when billing multiple quantities of a supply (for example, disposable diapers or sterile saline).
Certain procedure codes have been removed from modifier 91 auditing. These are procedure codes that have been identified as routinely being performed at the same time, more than twice per day for each antigen. Documentation of time is required. If not, the claim will be denied. Providers may appeal claims that have been denied for documentation of time. Most procedure codes initially requiring modifier 91 continue to be audited for modifier 91.
When appealing claims with modifier 91 for repeat procedures, providers must separate the details. One detail should be appealed without the modifier and one detail with the modifier including documentation of times for each repeated procedure.
Refer to: Chapter 7, "Appeals and Administrative Review".
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