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Appropriate Use of Modifier 76 and 91

April 27, 2012

On April 18, 2011 Blue Cross and Blue Shield of Oklahoma (BCBSOK) implemented ClaimsXten™, a code auditing tool developed by McKesson Information Solutions, Inc. One feature of this tool is the Modifier-to-Procedure Validation editing. Since the implementation of ClaimsXten, BCBSOK has noticed an increase in the use and potential misuse of modifiers 76 and 91.

Modifier 76 is reported to communicate that a service or procedure was repeated by the same practitioner subsequent to the original procedure or service. Without the modifier, subsequent reporting of the same procedure by the same provider could mistakenly be interpreted as being a duplicate. This modifier may be used whenever the circumstances warrant the repeat procedure. Based on the definition of modifier 76, it would be inappropriate to append modifier 76 to clinical laboratory tests on the same day. CPT codes for use with modifier 76 are 10021-69990, 70010-79999, 90281-99199, and 99500-99607, when appropriate.

Modifier 91 is used to report repeat laboratory tests or studies performed on the same day on the same patient. This modifier is added only when additional test results are to be obtained subsequent to the initial administration or performance of the test(s) on the same day. It is not used when laboratory tests or studies are simply rerun because of specimen or equipment error or malfunction. Nor is it to be used when a test is repeated to confirm initial test results. Further, based on the definition of modifier 91, it should not be reported when the basic procedure code(s) indicate that a series of tests are to be obtained. CPT codes for use with modifier 91 are in the laboratory code range 80047-89398.

Clear Claim Connection™ (C3) will continue to be the provider resource that allows disclosure of claim auditing rules and clinical rationale to the BCBSOK independently contracted provider network. C3 is a free online tool available to providers who are registered with Availity®. After logging on to the Availity provider portal , look for Claims Management/Research Procedure Code Edit. If you are not currently a registered user, visit Availity  to sign up.

To access Clear Claim Connection, you will need to register with one of the following web based portals; Availity  or RealMed . For your reference, we have provided log-in instructions:

Availity instructions 

RealMed instructions 

Once you have entered Clear Claim Connection, you have the ability to enter claims data in order to display the claims auditing results. If you would like more information you may contact your local Professional Provider Network office or Provider Customer Service at 800-451-0287.

For more information about Clear Claim Connection, along with ClaimsXten™ Frequently Asked Questions (FAQs), visit the Education and Reference Center/Provider Tools section of our website at bcbsok.com/provider.

CPT copyright 2010 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc.

Availity is a registered trademark of Availity, L.L.C. McKesson Information Solutions, Inc. and Availity, L.L.C. are independent third party vendors and are solely responsible for their products and services. BCBSOK makes no representations or warranties regarding the products or services provided by either of these vendors. If you have any questions regarding the products or services provided by these vendors, you should contact the vendor(s) directly.