Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 76: Repeat Procedure or Service by Same Physician or Qualified Health Professional

Policy #:03.00.02b


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Modifier 76 is used to indicate that a procedure or service was repeated on the same day in a different session by the same professional provider. When an initial procedure or service is covered, the repeated procedure or service is eligible for separate reimbursement.

It is appropriate to append Modifier 76 when all of the following circumstances are met:
  • The procedure or service is repeated by the same professional provider
  • The procedure or service that is repeated is performed either on the same date of service or within 24 hours of the initial procedure or service.
  • The same procedure code is reported for both the initial and repeated procedure or service.
  • The circumstances requiring a repeat of the procedure or service are as follows:
    • A change occurs in the physical status or diagnosis of the individual.
OR
    • Subsequent to the initial procedure or service, a different procedure or service is performed that necessitates the repetition of the initial procedure or service for diagnostic or confirmatory purposes.
  • Supporting medical necessity documentation is maintained in the medical record.
    • The member's medical records must be available to the Company upon request.

It is inappropriate to append Modifier 76 in the following circumstances:
  • When the subsequent procedure or service is performed by a different professional provider
    • To indicate a repeated procedure or service by a different professional provider, refer to the policy addressing Modifier 77: Repeat Procedure or Service By Another Physician or Other Qualified Health Care Professional
  • When the subsequent procedure or service is not a repeat of the same procedure or service
  • When the subsequent procedure or service is not performed within a 24-hour period of the initial procedure or service
  • When the code narrative indicates that the procedure or service represents a bilateral or multiple procedure, unless the bilateral or multiple procedure or service is repeated in its entirety
  • When the modifier is used in lieu of a more appropriate service modifier (e.g., bilateral (-50), multiple procedure (-51) or right/left (RT/LT))
  • When the procedure or service performed should be reported with an appropriate add-on code
  • When the modifier is appended to an Evaluation and Management service
  • When the modifier is appended to a Laboratory service
    • To indicate a repeated Laboratory service append modifier 91
  • When the service is repeated as a result of a malfunction in equipment, error in its initial performance, and/or unsatisfactory results of its initial performance


REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, repeat procedures or services by the same professional provider are covered under the medical benefits of the Company's products.

This policy is consistent with Current Procedural Terminology (CPT) and Centers for Medicare & Medicaid Services' (CMS) reporting requirements.

BILLING GUIDELINES

When it is medically necessary to repeat a procedure or service, the initial procedure or service should be reported in the usual manner. The repeated procedure or service should be reported on the subsequent line of the claim following the initial procedure or service, with Modifier 76 appended to the repeated procedure code.
  • The Company requires that the documentation supports the medical necessity of the repeated procedure or service
    • An explanation of medical necessity for the repeated procedure is necessary otherwise the service may be denied for coverage and reimbursement consideration
  • Regardless of the number of times the same procedure or service is repeated (by the same provider, on the same day, or 24-hour period), the same procedure code is reported for each repetition of the procedure or service, appended with Modifier 76.
  • Repeat surgical procedures are subject to standard multiple surgical reduction guidelines.


  • Description

    It may be determined by a professional provider that it is medically necessary to repeat a procedure or service on an individual. When a procedure or service is repeated within 24-hours of the initial encounter, Modifier 76 is used to report the repeated procedure or service. The circumstances requiring that a procedure or service be repeated can include, but are not limited to, a change in a individual's physical status, services repeated for comparative purposes, follow-up after treatment or intervention, tests repeated at different intervals, etc.


    Modifier 76 describes a repeated procedure or service by the same professional provider. The modifier should be utilized by a professional provider to indicate that the claim submitted is not duplicative.


    References


    Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 4: Part B Hospital (Including Inpatient Hospital Part B and OPPS). [CMS Web site]. 9/06/19. Available at:
    https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c04.pdf.Accessed Septermber 16, 2019.

    Centers for Medicare & Medicaid Services. National Correct Coding Initiative Edits. [CMS Web site]. 7/16/2019. Available at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd. Accessed September 16, 2019.

    Highmark Provider Resource Center. Highmark Provider Manual: Chapter 6.4 Billing & Payment: Professional (1500/837P) Reporting Tips. April 2018. Available at:
    https://content.highmarkprc.com/Files/EducationManuals/ProviderManual/hpm-chapter6-unit4.pdf. Accessed September 17, 2019.

    Noridian Healthcare Solutions. Modifier 76. 10/25/2018. Available At:
    https://med.noridianmedicare.com/web/jfa/topics/modifiers/76. Accessed September 16, 2019.

    Novitas Solutions, Inc. Modifier 76. 9/10/2019. Available At:
    https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00092327. Accessed September 16, 2019.

    Optum360. Understanding Modifiers 2019. West Salt Lake City, UT: Optum360; 2018.


    Coding

    Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

    The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

    In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

    The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

    CPT Procedure Code Number(s)

    N/A


    Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

    Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


    ICD-10 Procedure Code Number(s)

    N/A


    Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

    Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


    ICD-10 Diagnosis Code Number(s)

    N/A


    HCPCS Level II Code Number(s)





    Revenue Code Number(s)




    Misc Code

    N/A:

    76Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional



    Coding and Billing Requirements


    Cross References


    Policy History

    This version of the policy will become effective 12/16/2019. This policy has been updated to reflect the revisions made by CMS and National Correct Coding Initiatives; the intent of the policy remains unchanged.
    Version Effective Date: 12/16/2019
    Version Issued Date: 12/16/2019
    Version Reissued Date: N/A



  • 2017 AmeriHealth.