Thursday, December 2, 2010

How to avoid duplicate denial when billing with modifier

Avoiding Duplicate Denials When Billing with Modifier 76

Modifier 76 is defined by the Current Procedural Terminology as "repeat procedure by same physician." This modifier is appropriate when necessary to report repeat procedures performed on the same day.

Some providers have experienced denials when using a 76 modifier on more than one line of service to indicate multiple procedures billed on the same date of service by the same physician for the same beneficiary.


Line     Procedure     Modifier     Quantity   
1     71275           1     Paid
2     71275     76     1     Paid
3     71275     76     1     Denied as duplicate

To avoid a duplicate denial for the 3rd and subsequent lines, providers can indicate in Loop 2400 MEA segment for electronic claims or in item 19 of the CMS 1500 claim form, the total number of services performed that day. For example, "71275 performed 3 times on 10-12-07"

For certain services providers may also avoid unnecessary duplicate denials by quantity billing those services on a single claim line.


Line     Procedure     Modifier     Quantity    
1     93010           3     Paid

Providers may contact Customer Service to verify whether a particular procedure may be quantity billed.

Preventing duplicate claim denials

Providers are responsible for all claims submitted to Medicare under their provider number. Preventable duplicate claims are counterproductive and costly, and continued submission to Medicare may lead to program integrity action.

Please share this information with your billing companies, vendors and clearing houses: Claim system edits search for duplicate, suspect duplicate and repeat services, procedures and items within paid, finalized, pending and same claim details in history. Duplicate claims and claim lines are automatically denied. Suspect duplicate claims and claim lines are suspended and reviewed by the Medicare administrative contractor (MAC) to make a determination to pay or deny. Click here for additional information.

Medicare correct coding rules include the appropriate use of condition codes and modifiers. When you submit a claim for multiple instances of a service, procedure or item, the claim should include an appropriate modifier to indicate that the service, procedure or item is not a duplicate. Note that the modifier should be added to the second through subsequent line items for the repeat service, procedure or item. An example is listed below. In many instances, this will allow the claim to process and pay, if applicable.

However, in some instances, even if an appropriate modifier is included, the claim may deny as a duplicate, based on medically unlikely edits (MUEs). MUEs are maximum units of service that are typically reported for a service, medical procedure or item, under most instances, for a beneficiary on a single date of service. Note that these duplicate denials may not always be considered preventable.

Review your billing procedures and software, and use appropriate modifiers, as applicable. The following are examples of modifiers that may be used on your claim to identify that the service, procedure or item is not a duplicate.

• Modifier 59: Service or procedure by the same provider, distinct or independent from other services, performed on the same day. Services or procedures that are normally reported together but are appropriate to be billed separately under certain circumstances

• The Centers for Medicare & Medicaid Services (CMS) established four new modifiers, effective January 1, 2015, to define subsets of modifier 59.

• Modifier 76: Repeat service or procedure by the same provider, subsequent to the original service or procedure.

• Modifier 91: Repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.

• Example: Laboratory submits Medicare claim for four glucose; blood, reagent strip tests (CPT� code 82948).

Line 1: 82948
Line 2: 82948 and modifier 91
Line 3: 82948 and modifier 91
Line 4: 82948 and modifier 91

• Modifiers RT (right side) and LT (left side): Append applicable modifier to the procedure code, even if the diagnosis indicates the exact site of the procedure.

• Example: Provider submits Medicare claim for diagnosis code M1711 (unilateral primary osteoarthritis, right knee) and/or diagnosis code M1712 (unilateral primary osteoarthritis, left knee). Modifier RT should be added to the procedure code billed with diagnosis code M1711. Modifier LT should be added to the procedure code billed with diagnosis code M1712.

Note: All claims submitted to Medicare should be supported by documentation in the patient’s medical record.

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