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Reflex Testing: Compliance, Billing and Coding

AUGUST 2010

As published in the Mississippi Medical News.

A "reflex" test is a procedure routinely added-on to a patient order when the initial test results are at a level that meets the clinician's threshold to automatically add specific tests. In a nutshell, they are protocols that specify if this then that. While this makes a great deal of common sense, care to dot all the I's and cross all the T's is the mainstay of billing and coding compliance. The documentation for dotting and crossing I's and T's is the heart of the compliance step.

The table (Table 1) provides examples of typical best practices for reflex that are standard nationwide.

There are several types of reflex tests.  Some are standards of practice (e.g., identification and susceptibility testing on positive cultures or identifying antibodies before transfusing a patient) and others are decided upon at the facility or department level with the approval of the medical staff. Physicians should be given the opportunity to "opt out" of the reflex protocol by notifying the testing department. 

Billing Reflex Tests

Billing of reflex testing is exactly like any other diagnostic test - it must be medically necessary (ie, necessary for the treatment, monitoring or diagnosis of the patient) and there must be an order such as an electronic or paper requisition or an annual physician acknowledgement that he/she is aware of and wants the reflex protocols unless specifically stated otherwise. 

Repeat Testing that is NOT Reflex Testing

In the clinical lab, "critical value" or "panic value" testing is often construed as reflex testing, but actually it is a quality assurance measure - the same procedure is repeated on the original sample and on a recollected sample. This scenario occurs when an initial result is so abnormal that the patient's life may be threatened.  Quality assurance testing is not billable. Adding a 91 modifier and billing for the repeated tests would be inappropriate. However, if the physician acts on the results of an abnormal result and orders a repeated sample, then the second test is indeed a medically necessary test (due to prior abnormal result) and is billable.

Example:   Patient A arrives in the ER unconscious and a battery of tests are performed. The glucose level is flagged in the laboratory as a critical value of 500 mg/dl. The lab immediately retests the sample while notifying the ER of the initial result. A redraw (or perhaps a point of care glucose) is performed with the result of 490 mg/dl. The medical team administers insulin and orders a repeat glucose.

Discussion: The initial glucose is billed. The retest to verify the critical value is not billed nor is the subsequent redraw which also verifies the critical result. The third sample (physician ordered) to monitor the patient, is billable. A -91 modifier will be required on the claim.

In the case of the reflex test, it is always best to have a signed and dated physician acknowledgement authorizing the reflex but it is physician's responsibility to opt out of established protocols. Most facilities that allow reflex testing have a policy requiring written physician orders to follow on all reflex protocols just as they do for verbal orders.
Reflex testing is not only acceptable but beneficial to the patient and the physician.  Documentation in the form of physician acknowledgements and "opt out" policies create a compliant billing opportunity as well.

Betty Hatten is a manager in health care services at HORNE LLP. Her primary responsibilities include oversight of the chargemaster assessment and maintenance team, as well as providing charge capture audits, performance improvement assessments, and focused compliance reviews. Betty is a frequent seminar presenter and customizes presentations for clients, hospital associations, and professional organizations on the local, regional and national level.