Do we still need to report modifier –L1?

Q: I was at a conference last week and while we were on a break, I heard someone say that we don’t have to use modifier -L1 (separately payable laboratory test) to get paid for lab work from Medicare. Is that true?

A: This is true, but not in all circumstances. Beginning January 1, CMS implemented new status indicator Q4 (conditionally packaged laboratory tests) for laboratory CPT® codes. This status indicator works like the other Q modifiers in that if it is the only service on a claim, the service will be reimbursed separately.

Q4 allows the I/OCE to process the claim and assign reimbursement for the services when Q4 services are the only services on the claim. So for a “lab only” claim, there is no longer a reason to apply the -L1 modifier. This is positive for facility providers from an operational standpoint.

Modifier -L1 has not been deleted because there may still be circumstances when it is appropriate to append the modifier. CMS did not change any of the criteria for applying the modifier, so all rules are still in place. But if the claim is for laboratory services only, status indicator Q4 erases the necessity of appending the modifier.

For more information, see Transmittal 3425 and the 2016 OPPS final rule.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.