CurrentAnthemPolicy G-20001

Modifier 90

Governs reimbursement for laboratory claims billed with modifier 90, specifying when pass-through billing in an office place of service (11) is eligible for payment and who receives reimbursement; applies to Anthem Blue Cross and Blue Shield Medicare Advantage lines as indicated in the document.

Policy Summary

PayerAnthem

PolicyModifier 90

Policy CodePolicy G-20001

Change TypeNo material change

Effective Date07/21/2025

Next Review Date

Key ActionClaims with modifier 90 billed in an office place of service (11) are not eligible for reimbursement unless contracts or regulations require otherwise; payment is made to the performing provider at 100% of the applicable fee schedule or contracted rate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%fee schedule paid to performing provider

POS 11office POS where ineligible

07/21/2025last approval/effective

multi-statestates applicability

Modifier 90 Coverage Criteria

Modifier 90 coverage criteria

Coverage and reimbursement rules for laboratory services billed with modifier 90.

Claims appended with modifier 90 billed in an office place of service (11) are not eligible for reimbursement unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Reimbursement will be made directly to the provider who performed the clinical diagnostic laboratory test at 100% of the applicable fee schedule or contracted/negotiated rate.

This policy does not apply to claims submitted from laboratory and pathology providers that are allowed to bill in an office place of service (11).

Modifier Coding

Modifier codingModifier

Modifier 90

Identifies laboratory procedures performed by a party other than the treating or reporting physician or qualified healthcare professional

Policy Summary

PayerAnthem

PolicyModifier 90

Policy CodePolicy G-20001

Change TypeNo material change

Effective Date07/21/2025

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing Rule

Reimbursement direction for Modifier 90 (pass-through billing)

Claims appended with modifier 90 billed in an office place of service (11) are not eligible for reimbursement unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Reimbursement will be made directly to the provider who performed the clinical diagnostic laboratory test at 100% of the applicable fee schedule or contracted/negotiated rate.

Exception: policy does not apply to claims submitted from laboratory and pathology providers allowed to bill in an office place of service (11).
Ensure services meet authorization and medical necessity guidelines and are supported by appropriate documentation and coding.

Definitions

Modifier 90 — definition of when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional

TermModifier 90

DefinitionWhen laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional, the procedure may be identified by adding modifier 90 to the usual procedure number.

Usage contextAppended to the usual procedure number to indicate a non-treating/performance party performed the laboratory procedure.

Pass-Through Billing — definition of when a provider pays a laboratory to perform their tests and then files the claims as though they had performed the tests themselves

TermPass-Through Billing

DefinitionWhen a provider, such as a physician or hospital, pays a laboratory to perform their tests and then files the claims as though they had performed the tests themselves.

ImplicationIndicates the billing provider did not perform the laboratory tests but is submitting claims as if they did.

OpenPayer

Modifier 90

Modifier 90 Coverage Criteria

Modifier Coding

Provider Reimbursement Direction

Definitions