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What are modifiers for CPT code 85049 "Bloodcount; platelet, automated" and why should I use them?

As medical coding professionals, we are all responsible for ensuring accuracy and completeness of the medical records. When billing for procedures and services, it is crucial to apply the appropriate modifiers to reflect the circumstances of the service performed. For example, CPT code 85049, which is used for "Bloodcount; platelet, automated," may be used for various situations. The use of appropriate modifiers can enhance the clarity and precision of the submitted medical claims, minimizing the potential for denials and ensuring timely and accurate reimbursement. The American Medical Association (AMA) owns these codes and updates the CPT codes every year. It is required to pay the AMA for using the CPT code for billing. Failing to do so could lead to legal actions. It is recommended to always get a license from the AMA and use the latest published version of the CPT book from the AMA website. We, at [Your organization name], have compiled this information and this article is intended to help you in your medical coding journey.

When and why to use modifiers for CPT Code 85049: Bloodcount; platelet, automated

Using modifiers for CPT code 85049 can reflect the specifics of the service provided. Let's explore some examples:

Modifier 59: Distinct Procedural Service

Imagine you are coding a patient encounter where a physician has ordered a comprehensive metabolic panel (CMP) and a platelet count (CPT Code 85049). While the CMP would usually include a platelet count, let's assume the physician wants a separate platelet count. In this scenario, you would need to append modifier 59 to 85049, indicating a distinct procedural service.

This is a scenario where using modifier 59 could be used for "Bloodcount; platelet, automated". It is because, in most instances, a comprehensive metabolic panel (CMP) includes a platelet count, a complete blood count (CBC) or an automated blood count usually includes a platelet count. The platelet count would be considered an intrinsic part of those tests and not an individual separate service. Therefore, when you bill a "Bloodcount; platelet, automated" code alone you would typically not use modifier 59 as it is not a "Distinct Procedural Service".

Here is a story to illustrate: A patient presented to the clinic with signs and symptoms suggestive of dengue fever. They reported bleeding gums and bruising. Upon questioning, it came to light that the patient also has a long-standing history of atrial fibrillation (AF) and is on Coumadin therapy.

In this scenario, the healthcare provider ordered a CBC and CMP, along with a separate "Bloodcount; platelet, automated" test (CPT code 85049), for the patient because it was suspected the patient has low platelets (thrombocytopenia), making them more vulnerable to bleeding episodes. This test is critical to assess the risk of further bleeding while they are on Coumadin. Since the platelet count was ordered separately for a different reason than the CBC and CMP, we would append modifier 59 to 85049 in this case. This signifies that this platelet test was not an integral component of the other two tests. By appending modifier 59 to CPT code 85049, we've accurately captured the distinct nature of the platelet count. This modification could save you from denials, ensure that the medical bill reflects the complete picture of the care provided, and facilitate appropriate reimbursement.

Modifier 90: Reference (Outside) Laboratory

Modifier 90 signifies a test that was conducted by an external laboratory. Let’s consider this use case: Imagine a scenario where a patient has been referred to a hematologist and has been advised to do a comprehensive blood count (CBC). The Hematologist prefers that a particular outside lab performs the test and gives a specialized interpretation report that is particularly beneficial to them.

You would need to append Modifier 90 to CPT code 85049, in this instance. Using modifier 90 ensures that the lab performing the service is recognized in the billing. This modifier clarifies that the CBC was performed in an external lab as opposed to the Hematologist's facility, as well as facilitating correct billing.

Modifier 91: Repeat Clinical Diagnostic Laboratory Test

We need to be cognizant of when a particular blood count, such as platelet count, has already been ordered and completed, for example, within a specific timeframe. Let’s consider this: If the patient undergoes multiple CBCs and CMPs in the same hospital admission or observation period (typically 30 days). For example, let's assume a patient is admitted to a hospital with acute shortness of breath, and upon reviewing their lab results, you notice the patient's platelet count is abnormal. Due to concerns about bleeding episodes, a repeat "Bloodcount; platelet, automated" (CPT code 85049) is ordered 2 days later, on day 3 of hospitalization.

In this situation, Modifier 91 would apply to code 85049 because the second "Bloodcount; platelet, automated" is a repeat lab test during a short timeframe. The use of Modifier 91 can protect against overbilling. Modifiers can clarify why an extra or repeated procedure was conducted and if there was a different rationale behind it. Using a modifier will allow the health insurance provider to properly and timely evaluate the bill, avoid denials and expedite the payment process.

Modifier 99: Multiple Modifiers

This modifier is rarely used, especially in medical coding. However, if there are multiple reasons why the service was modified or if multiple aspects of the procedure warrant further clarification using different modifiers, then using Modifier 99 would be useful.

Let's GO back to our previous example. A patient presented to the clinic with signs and symptoms suggestive of dengue fever. They reported bleeding gums and bruising. They have been advised to undergo CBC, CMP, and "Bloodcount; platelet, automated" (CPT Code 85049), for a clear picture of their blood conditions and coagulation profiles. The doctor suspects that this will require them to consult a hematologist and get the specialized reports on their blood conditions from an outside lab. In this scenario, both Modifier 90 and 59 might be required. Modifier 59 because this test was distinct from CMP and CBC, and modifier 90 because the hematologist asked for reports from a specific external lab, not the doctor’s facility.

Instead of putting both modifiers together separately, the 99 modifier allows you to indicate to the payer that multiple modifiers apply.

Modifier 99 does not replace the requirement to append the specific applicable modifiers. The "99" Modifier is a notification that multiple modifiers are attached to a procedure. In the event that all appropriate modifiers are appended to the procedure, modifier "99" is not utilized.

This article is not exhaustive, and for complete details of using modifier and CPT codes, refer to the current version of the CPT Manual provided by AMA. We strongly advise all medical coding professionals to obtain the license from AMA to use the codes and refer to the updated CPT coding manual as it can prevent penalties and fines.

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What Modifiers Should I Use with CPT Code 85049 "Bloodcount; Platelet, Automated"?