Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 77: Repeat Procedure by Another Physician

Policy #:03.00.11a

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

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

The Company has established the following requirements to report Modifier 77 with the procedure codes listed in the Coding Table:
  • The repeated procedure or service is performed by a physician other than the one who performed the procedure or service initially.
  • The repeated procedure or service is the same as the initial procedure or service.
  • The same procedure code is reported for both the initial and repeated 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 events precipitating the repeat of the same procedure or service by another physician are as follows:
    • A change occurs in the physical status or diagnosis of the patient.
    • Subsequent to the initial procedure or service, a different procedure or service is performed necessitating the repeat of the initial procedure or service for diagnostic or confirmatory purposes.
  • Supporting medical necessity documentation is maintained in the medical record describing the circumstances precipitating the repetition of the procedure or service.
    • The member's medical records must be available to the Company upon request.

The following are inappropriate uses of Modifier 77 and will, therefore, not be considered for separate reimbursement:
  • When any of the required criteria for reimbursement are not met
  • When the subsequent procedure or service is performed by the same physician who performed the initial procedure or service
  • When the subsequent procedure or service is not a repeat of the same procedure or service on the same lesion and/or body part
  • When the subsequent procedure or service is not performed during the same 24-hour period
  • The subsequent procedure or service performed is more accurately described by a different procedure code and/or modifier
  • When the procedure code narrative indicates that the procedure code represents a bilateral or multiple procedure, unless the bilateral or multiple procedure is repeated, in its entirety

Guidelines

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


ADDITIONAL MODIFIER 77 REPORTING INFORMATION
  • The reason for the repeat of the procedure or service by another physician should be provided in the narrative field of the claim line to support the medical necessity of the repeated services.
    • Medical records, notes, or other supporting documentation should not be appended to the claim unless specifically required and/or requested by the Company.
  • If the physician who repeats the initial procedure or services performs the repeated procedure or services more than once, the procedures should be reported as follows:
    • The first time the procedure is repeated by another physician, 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 physician.

The 77 modifier is used for a procedure performed that has had to be repeated by another physician, in a separate session, on the same day. The procedure is reported on the claim form appended with Modifier 77. When a procedure or service is repeated by the same physician, refer to the policy addressing Modifier 76.


PROVIDER TYPES:
  • The 77 modifier may be reported for services ordered by physicians but performed by other eligible providers (eg, technicians).
  • The 77 modifier may be reported by individual physicians.
  • Facilities are not required to append repeated outpatient procedures with Modifier 77.

This policy is applicable to all products.
Description

There are circumstances in which a procedure or service is repeated on the same day by a physician other than the physician who initially performed the procedure or service. Procedure code Modifier 77 is appended to the procedure code to denote this information.

For the purpose of this policy, physician refers to any eligible provider.
References


Beebe M, Dalton JA, Duffy C, et al, eds. CPT® 2007 Current Procedural Terminology. 4th ed. (Revised 2006). Chicago, IL: American Medical Association (AMA) Press; 2006: 292.

Centers for Medicare & Medicaid Services (CMS). Intermediary Manual. Part 3. Chapter VII, Bill Review. §3627.11: Use of modifiers in reporting hospital outpatient services. [CMS Web site]. 01/01/98. Available at: http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS021918&intNumPerPage=2000 (zip folder document: a3 3620_to_3620.11.doc). Accessed May 17, 2007.

Centers for Medicare & Medicaid Services (CMS). Program Memorandum. Transmittal No. A-00-73: Clarification of Modifier Usage in Reporting Outpatient Hospital Services. [CMS Web site]. 10/05/00. Available at: http://www.cms.hhs.gov/transmittals/downloads/A0073.PDF. Accessed May 17, 2007.

Empire Medicare Services. Introduction to Medicare 2006. Chapter 24: Frequently Used Modifiers. [Empire Medicare Services Web site]. 05/03/06. Available at: http://www.empiremedicare.com/trainb/pdf/pet0023.pdf. Accessed May 17, 2007.

Empire Medicare Services. Medicare News Brief. New Jersey (Part B). MNB-2003-1: Repeat services on the same day. [Empire Medicare Services Web site]. 01/01/03. Available at: http://www.empiremedicare.com/cbriefs/2003%2D1/rep.htm. Accessed May 17, 2007.

Hall DC, Orme N, eds. 2007 Ingenix University: Understanding Modifiers. Salt Lake City, UT: Ingenix, Inc.; 2006.

Highmark Medicare Services. Medicare Part B Reference Manual. Appendix B, Modifiers. 77: Repeat procedure by another physician. Revision 065. [Highmark Medicare Services]. Original: 07/01/05. (Revised: 01/01/07.) Available at: http://www.highmarkmedicareservices.com/partb/refman/pdf/appendix-b.pdf. Accessed May 17, 2007.


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)

All CPT codes may be appended with Modifier 77.


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)

All HCPCS codes may be appended with Modifier 77.


Revenue Code Number(s)

N/A


Misc Code

Modifier:

77: Repeat procedure by another physician


Coding and Billing Requirements


Cross References


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 11/24/2003
Version Issued Date: 12/27/2005
Version Reissued Date: 06/20/2007

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