Monday, November 29, 2010

Repeat Procedures modifiers 76 & 77

Repeat Procedures

Modifier 76: Denotes a repeat procedure by the same physician. Should be submitted only when a procedure is repeated on the same date of service by the same physician

Modifier 77: Denotes a repeat procedure by another physician. Should be submitted only when a procedure is repeated on the same date of service by another physician.

Repeat Procedure by Another Physician or Other Qualified Health Care Professional: It may be necccesary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service.

NOTE for Modifiers 76 and 77: The procedure must be the same procedure. It is submitted on the claim form once and then listed again with the appropriate modifier.


Two repeat procedure modifiers are applicable for hospital use:

• Modifier -76 is used to indicate that the same physician repeated a procedure or service in a separate operative session on the same day.

• Modifier -77 is used to indicate that another physician repeated a procedure or service in a separate operative session on the same day.

If there is a question regarding who the ordering physician was and whether or not the same physician ordered the second procedure, the code selected is based on whether or not the physician performing the procedure is the same.

The procedure must be the same procedure. It is listed once and then listed again with the appropriate modifier.

Modifier 76 Definition


Usage of Modifier 76 Instructions

Used to indicate a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service.

Correct Use

    Procedure or service is usually performed on the same day
    Append 76 modifier to the repeated procedure or service CPT code only
    When two physicians are within the same group or same specialty = same physician
    Used for surgeries, x-rays and injections

Incorrect Use

    Not appropriate with laboratory or pathology codes(append modifier 91)
    Not appropriate to use with equipment failure
    Should not be appended to an E/M service
    Does not replace modifiers such as RT, LT, 50, E1-E4, FA, F1-F9, TA, and T1-T9

Modifier 76 is used to designate a repeat study on the same date of service for the same patient by the same physician or healthcare provider.

Modifier 76 does not provide for reimbursement of an ineligible service and no additional reimbursement will be issued for services if the reimbursement to the physician is via capitation.

Horizon BCBSNJ will reimburse repeat procedures or services performed by the same physician for the same patient on the same date of service appropriately appended with Modifier 76 at the applicable fee schedule amount when the procedure(s) meet the  guidelines cited below. Any procedure that does not meet the guidelines below will not be reimbursable.

To help ensure the accurate adjudication of claims, we ask that you adhere to the following Modifier 76 guidelines:

Modifier 76 is used to designate a repeat study on the same date of service for the same patient by the same physician or healthcare provider.

BCBSGA Medicare Advantage allows reimbursement for applicable procedure codes appended with Modifier 76 to indicate a procedure or service was repeated by the same physician:

** Subsequent to the original procedure or service for professional provider claims

** On the same date as the original procedure or service for facility claims

Unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise, reimbursement is based on the following use of Modifier 76:

** For a nonsurgical procedure or service: 100 percent of the applicable fee schedule or contracted/negotiated rate

** For a surgical procedure: 100 percent of the applicable fee schedule or contracted/negotiated rate for the surgical component only limited to a total of two surgical procedures

Professional services, other than radiology which is excluded from this requirement, will be subject to clinical review for consideration of reimbursement. Providers must submit supporting documentation for the use of Modifier 76 with the claim. If a claim is submitted with Modifier 76 without supporting documentation, the claim will be denied. Providers will be asked to submit the required documentation for reconsideration of reimbursement. Failure to use Modifier 76 when appropriate may result in denial of the procedure or service.

 If a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries,  ssistant surgeon and/or multiple procedure rules and fee reductions apply


Amerigroup allows reimbursement for applicable procedure codes appended with Modifier 76 to indicate a procedure or service was repeated by the same physician:

* Subsequent to the original procedure or service for professional provider claims

* On the same date as the original procedure or service for facility claims Unless provider, state, federal or CMS contracts and/or requirements indicate otherwise, reimbursement is based on the following use of Modifier 76:


* For a nonsurgical procedure or service: 100 percent of the applicable fee schedule or contracted/negotiated rate

* For a surgical procedure: 100 percent of the applicable fee schedule or contracted/negotiated rate for the surgical  omponent only limited to a total of two surgical procedures

Professional services, other than radiology which is excluded from this requirement, will be subject to clinical review for consideration of reimbursement. Providers must submit supporting documentation for the use of Modifier 76 with the claim. If a claim is submitted with Modifier 76 without supporting documentation, the claim will be denied. Providers will be asked to submit the required documentation for reconsideration of reimbursement. Failure to use Modifier 76 when appropriate may  result in denial of the procedure or service.

If a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply.

This modifier should not be appended to an E/M service. To report a separate and distinct E/M service performed on the  same date, see modifier 25. It is also inappropriate to use modifier 76 to indicate repeat laboratory services. Modifiers 59 or 91 should be used to indicate repeat or distinct laboratory services, as appropriate according to the AMA and CMS. Separate consideration for reimbursement will not be given to laboratory codes reported with modifier 76.


Non reimbursable

BCBSGA Medicare Advantage does not allow reimbursement for use of Modifier 76:

** With an inappropriate procedure code(e.g., laboratory/pathology)
** For a surgical procedure repeated more than once
** For the preoperative or postoperative components of a surgical procedure


It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.

Note: This modifier should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25. It is also inappropriate to use modifier 76 to indicate repeat laboratory services. Modifiers 59 or 91 should be used to indicate repeat or distinct laboratory services, as appropriate according to the AMA and CMS. Separate consideration for reimbursement will not be given to laboratory codes reported with modifier 76

When entering a pricing modifier, enter it in the first modifier field only. As an example, when billing for the professional component (26) or the technical component (TC) enter the 26 or the TC modifier in the first modifier field.

When entering a pricing modifier and a statistical modifier that affects pricing;

enter the pricing modifier in the first modifier field and the statistical modifier that affects pricing in the second modifier field. As an example, when billing for the   professional component (modifier 26) in a Health Professional Shortage Area (HPSA) (modifier QB) enter 26 in the first modifier field and QB in the second modifier field.


When entering a statistical modifier that affects pricing and a statistical/informational modifier, enter the statistical modifier in the first field and the statistical/informational modifier in the second field. As an example, when billing for the professional component (modifier 26) and repeated procedure by the same physician (modifier 76) enter 26 in the first modifier field and the 76 in the second modifier field.



Case Studies

Example 1: A provider received duplicate payments of $87.45 on 4/13/12 and 5/5/12 for CPT 71020 (Chest x-ray) with billed date of service of 3/29/12. Both claims were billed for same patient, same provider, and same date of service, same charge, same CPT code, and same units, without a modifier. The duplicate billing increased the subscriber’s liability by $53.00.

Resolution: Billing of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or 77 (repeat procedure or service by another physician or othe  qualified health care professional) should be used to report the performance of multiple diagnostic services on the same day if these were not actually duplicate claims.


Example 2: A provider received duplicate payments of $64.19 on 2/22/12 and 4/20/12 for CPT 77080 Dual-energy X-ray absorptiometry (DXA), Bone Density axial) with billed date of service of 1/31/12. Both claims were billed for the same patient, same provider, and same date of service, same charge, same CPT code, and same units, without a modifier.


Resolution: Billing of modifier 76 or 77 should be used to report the performance of multiple diagnostic services on the same day if these were not actually duplicate claims.


Usage of Modifier 77 Instructions

This modifier is appended to a repeated service from other physicians.

Correct Use

    Service originally performed by another physician
        Documentation must include reason for repeat procedure
        E.g., suspicious findings in original x-ray or EKG

Incorrect Use

    Not appropriate if repeated by same physician

Claim Coding Example

Physician and Treatment Description


CPT/Modifier

Dr. Modi

Radiologic exam; spine, single view


72020

Dr. Fier

Radiologic exam; spine, single view



72020 77

Example 1: A provider received duplicate payments of $87.45 on 4/13/12 and 5/5/12 for CPT 71020 (Chest x-ray) with billed date of service of 3/29/12. Both claims were billed for same patient, same provider, and same date of service, same charge, same CPT code, and same units, without a modifier. The duplicate billing increased the subscriber’s liability by $53.00.

Resolution: Billing of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or 77 (repeat procedure or service by another physician or other  qualified health care professional) should be used to report the performance of multiple diagnostic services on the same day if these were not actually duplicate claims.

Use modifier 77 to report the same procedure performed more than once on the same date of service but at different encounters.

Amerigroup allows reimbursement for applicable procedure codes appended with Modifier 77 to indicate a procedure or service was repeated by another physician:

** Subsequent to the original procedure or service for professional claims

** On the same date as the original procedure or service for facility claims Unless provider, state, federal or CMS contracts and/or requirements indicate otherwise, reimbursement is based on the following use of Modifier 77:

** For a nonsurgical procedure or service: 100 percent of the applicable fee schedule or contracted/negotiated rate

** For a surgical procedure: 100 percent of the applicable fee schedule or contracted/negotiated rate for the surgical component only limited to a total of two surgical procedures

Professional services, other than radiology which are excluded from this requirement, will be subject to clinical review for consideration of reimbursement. Providers must submit supporting documentation for the use of Modifier 77 with the claim. If a claim is submitted with Modifier 77 without supporting documentation, the claim will be denied. Providers will be asked to submit the required documentation for reconsideration of reimbursement. Failure to use Modifier 77 when appropriate may result in denial of the procedure or service.

If a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply.

Modifiers 76 and 77

• Procedure or service repeated in a separate session on the same day by

• same physician (Modifier 76)

• another physician (Modifier 77)

• May be reported for services ordered by a physician but performed by a technician


• The same procedure must be done in a separate session on the same day

• The procedures are reported on  two lines, the second with Modifier 76 or 77


Multiple Procedure Modifiers 76 & 91

Modifier 76 is used to report a service or procedure that was repeated by the same practitioner subsequent to the original service or procedure. Modifier 76 is applicable to code ranges 10021-69990, 70010-79999, 90281-99199, and 99500-99607. Example: 93000 & 93000-76.

Modifier 91 is used to report repeat laboratory tests or studies performed on the same day one the same patient. Modifier 91 is applicable to code range 80047- 89398. Example: 82962 & 82962-91.

If billing the EXACT same procedure code two or more times for the same date of service, the claim should be submitted with the procedure code listed on one line without the 76 or 91 modifier and each subsequent procedure listed on a separate line using the Modifier 76 or 91.

Providers should know this new edit will trigger by File Date, not Date of Service.



Medicare and Medicaid Guideline


Modifier 77: Repeat Procedure by Another Physician or Other Qualified Health Care Professional

Description:

It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service.

This modifier can be located in the following rule(s):
* Global Maternity
Is this modifier supposed to be listed in one of the frequency policies

* This modifier can be used to override an edit.


QDCs must be submitted with a line-item charge of $0.01 at the time the associated covered service is performed:

• The line item charge should be $0.01 – the beneficiary is not liable for this nominal amount.

• Entire claims with a $0.01 charge will be rejected.

• The $0.01 charge is submitted to the MAC and then the PQRS code line will be denied but will be tracked in the National Claims History (NCH) for analysis.

When a group bills, the group NPI is submitted at the claim level; therefore, the individual rendering/performing physician’s NPI must be placed on each line item (field 24J on CMS-1500 form or electronic equivalent; form locators 56, 76, 77, 78 and 79 on CMS 1450 form), including all allowed charges and quality-data line items. Solo practitioners should follow their normal billing practice of placing their individual NPI in the billing provider field (#33a on the  CMS-1500 form or the electronic equivalent or form locators 56, 76, 77, 78 and 79 on CMS 1450 form).


General Information

Modifier 77 is appended to report that a diagnostic procedure or service had to be repeated by a different provider on the same date of service.

Policy Modifier 77 indicates that a repeat procedure performed by a different provider was medically necessary and is not a duplicate billing of the original procedure done on the same date of service.

Billing

 • Modifier 77 is used only if the subsequent repeat procedure is billed by a different provider on the same date of service and with the same procedure code as the original procedure. In the example of billing for before and after films of a fracture treatment, the “after” films are billed with modifier 77.
Example: A motor vehicle accident patient complaining of chest pain radiating to his jaw and arm is transported to a local hospital. An EKG (93000) is performed and an arrythmia is noted. The patient sustained serious injuries that cannot be treated at this hospital and he is transferred to a regional medical center. The patient arrives at the regional medical center with increased chest pain, fever, nausea, and tachycardia. The ER physician performs another EKG to rule out myocardial infarction. Procedure code 93000 appended with modifier 77 should be submitted.






Modifier 77 usage - Fetal Non-Stress Test

Per coding guidelines from the December 2008 CPT Assistant, multiple non-stress tests performed on a single fetus on the same day should be reported with CPT code 59025 for the initial test. Code 59025 should be reported subsequently with modifier 76, to identify the repeated procedure(s) by the same physician; or with modifier 77 appended, to identify that the repeated procedure(s) was performed by another physician.

Multiple non-stress tests performed on twin gestations should be reported in the following manner:
* The initial test for the first fetus is reported using CPT code 59025; if subsequent testing is performed on the same fetus. CPT code 59025 is then reported a second time with modifier 76, to identify the repeated procedure by the same physician; or with modifier 77, to identify that the non-stress test was repeated by another physician.

* The initial test for the second fetus is reported using CPT code 59025 with modifiers 59, XE, XP, XS or XU appended, to identify that a separate fetus is being evaluated. If subsequent testing is performed on the second fetus, CPT code 59025 with modifiers 59, XE, XP, XS or XU is reported a second time with modifier 76, to identify the repeated procedure by the same physician; or modifier 77, to identify that the non-stress test was repeated by another physician. Please refer to the Definitions section of this policy regarding modifiers 59, XE, XP, XS or XU.


Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional
It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service.


Modifier 77: Repeat Procedure by Another Physician or Other Qualified Health Care Professional Description:

It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service.

This modifier can be located in the following rule(s):
* Global Maternity Is this modifier supposed to be listed in one of the frequency policies
* This modifier can be used to override an edit.

Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period Description:

It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)

This modifier can be located in the following rule(s):

* Global Procedure Days/Package

* Global Maternity Is this modifier supposed to be listed in one of the frequency policies

* This modifier can be used to override an edit.

Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period Description:

The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)

This modifier can be located in the following rule(s):

* Global Procedure Days/Package

* Global Maternity Is this modifier supposed to be listed in one of the frequency policies

* This modifier can be used to override an edit. Modifier 80: Assistant Surgeon Description: Surgical assistant services may be identified by adding modifier 

2 comments:

  1. The fee-for-service model depends solely on financial gain from charge those whom pays only if the automobile transports them to a destination. This leaves an outsized quantity of your time once the automobile is in commission however not occupied with a decision, for more information click here suboxne north palm beach,

    ReplyDelete
  2. Shall we use the 76 modifer for J codes? (Same Drug but different NDC#)

    EX: J9999 ( 1. NDC#) 400mg Dosage
    J9999 76 (2. NDC#) 200mg Dosage

    ReplyDelete

Most read cpt modifiers