Date: May 7, 2018
To: Enrolled Hospitals: Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers; and Independent Laboratories
Re: Clarification Regarding Use of Modifier 90 [Reference (Outside) Laboratory] for Hospital Outpatient Claims Billed on the 837P or HFS 2360 Claim Formats
The new HFS billing requirement for modifier 90 will apply to claims submitted for patients in a HealthChoice Illinois MCO, as well as traditional fee-for-service Medicaid. Modifier 90 is not required on Medicare crossover claims.
The HFS billing requirement for modifier 90 [Reference (Outside) Laboratory] is only pertinent to non-Ambulatory Procedures Listing lab services billed using either the 837P or HFS 2360 claim format. It does not apply to the institutional UB-04 or 837I claim formats. If a hospital is billing for the global service (professional and technical components) because a reference lab completed the service, modifier 90 must be used; otherwise, modifier 90 should not be used.
For laboratory services in the hospital outpatient setting, hospitals may bill for the technical component when the hospital obtains the specimen and completes the test. The claim for the professional services of the pathologist, whether the pathologist is salaried by the hospital or not, must be submitted under the name and NPI of the pathologist.
The Department is extending the effective date for hospitals to comply with the modifier requirement to June 1, 2018, to allow more time for hospitals and MCOs to update their processing systems.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.
Felicia F. Norwood