Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional
Policy #:MA03.007a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

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.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

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

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

Modifier 77 is used to indicate that a procedure or service repeated on the same day in a different session is needed to be performed by a different 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 77 when all of the following circumstances are met:
  • The repeated procedure or service is performed by a professional provider other than than the professional provider who performed the initial procedure or service.
  • The procedure or service is repeated in a separate session and 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 repeated procedure or service by another professional provider 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.
        OR
    • It is determined that a different professional provider is needed to obtain the necessary outcome.
  • 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 77 in the following circumstances:
  • When the subsequent procedure or service is performed by the same professional provider who performed the initial procedure or service
    • To indicate a repeated procedure or service by the same professional provider, refer to the policy addressing Modifier 76: Repeat Procedure or Service By Same Physician or Qualified Health 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 code 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 a Evaluation and Management procedure or service


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.
Policy Guidelines

BENEFIT APPLICATION

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

BILLING GUIDELINES
  • The Company requires that the documentation supports the medical necessity of the repeated procedure or service
    • An explanation of medical necessity for the repeat procedure is necessary; otherwise, the service may be denied for coverage and reimbursement consideration
  • When another professional provider repeats the initial procedure or service more than once, the procedures should be reported as follows:
    • The first time the procedure is repeated by another professional provider, the procedure code is appended with Modifier 77.
    • Each subsequently repeated procedure is not appended with Modifier 77.
    • In such instances, refer to the current policy addressing the 76 modifier for information regarding repeat procedures by the same professional provider

Modifier 77 is used to indicate a procedure or service that has had to be repeated by another professional provider, in a separate session, on the same day. The repeated procedure is reported on the claim form appended with Modifier 77. When a procedure or service is repeated by the same professional provider, refer to the policy addressing Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional.

Description

It may be determined that it is medically necessary for a professional provider to repeat a procedure or service that was initially performed by a different professional provider. When a procedure or service is repeated by another professional provider within 24-hours of the initial encounter, Modifier 77 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, to incur a better result, etc.

Modifier 77 describes a repeated procedure or service by a professional provider other than the provider who initially performed the service. This modifier should be utilized by the 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 September 16, 2019.

Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative Edits. [CMS Web site]. 7/16/2019. Available at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. 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 77. 10/25/2018. Available At:
https://med.noridianmedicare.com/web/jeb/topics/modifiers/77. Accessed September 19, 2019.

Novitas Solutions, Inc. Modifier 77. 02/13/2017. Available At:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00092116. Accessed September 19, 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)

N/A


Revenue Code Number(s)

N/A


Misc Code

MODIFIERS:

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


Coding and Billing Requirements


Cross References




Policy History

MA03.007a
12/16/2019This version of the policy will become effective 12/16/2019. It has been updated to reflect revisions made by CMS and National Correct Coding Initiatives.

MA03.007
01/01/2015This is a new policy.






Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A