Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 76: Repeat Procedure by Same Physician

Policy #:03.00.02a

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 76 with the procedure codes listed in the Coding Table:
  • 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 that is repeated 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 the same provider 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 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 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 76 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 a different provider
  • 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
  • When the subsequent procedure or service performed is more accurately described by a different procedure code
  • When, by definition, the code narrative indicates that the procedure code represents a bilateral or multiple procedure, and Modifier 76 is reported to indicate a procedure was performed bilaterally or multiple times, unless the bilateral or multiple procedure is repeated, in its entirety
  • When the repeat of the procedure is required due to an error in its initial performance and/or unsatisfactory results of its initial performance
    Guidelines

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

ADDITIONAL MODIFIER 76 REPORTING INFORMATION
When it is medically necessary to repeat a procedure or service, the initial performance of the procedure or service should be reported in the usual manner. The repeated procedure or service should be reported on a separate claim line following the initial procedure or service, with Modifier 76 appended to the repeated procedure code.
  • Regardless of the number of times the same procedure or service is repeated (by the same provider, on the same day, or within the same 24-hour period), the same procedure code is reported for each repeat of the procedure or service, appended with Modifier 76, on a separate claim line.
  • If a procedure or service is repeated (ie, performed more than once), the reason 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.
  • Repeat surgical procedures are subject to standard multiple surgical reduction guidelines.


PROVIDER TYPES:
  • Modifier 76 may be reported for services ordered by physicians but performed by other eligible providers (eg, technicians).
  • Modifier 76 may be reported by individual physicians.
  • Modifier 76 may be reported by hospitals for outpatient services, with the modifier appended to the procedure code in the appropriate hospital claim field.

This policy is applicable to all products.
Description

There are circumstances in which a procedure or service is repeated on the same day by the same physician. Procedure code Modifier 76 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: Claims Process. Chapter VII, Bill Review. §3627.11: Use of modifiers in reporting hospital outpatient services. [CMS Web site]. 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 file: a3 3620_to_3627.11.doc). Accessed May 17, 2007.

Centers for Medicare & Medicaid Services (CMS). Program Memorandum. Intermediaries. Transmittal No. A-00-73: Clarification of modifier usage in reporting outpatient hospital services. [CMS Web site]. 10/05/2000. Available at: http://www.cms.hhs.gov/transmittals/downloads/A0073.PDF. Accessed May 17, 2007.

Empire Medicare Services. Medicare News Brief. MNB-2003-1: Repeat services on the same day. [Empire Medicare Services Web site]. January 2003. Available at: http://www.empiremedicare.com/cbriefs/2003%2D1/rep.htm. 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.

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. 76: Repeat procedure by same physician. [Highmark Medicare Services Web site]. January 2007. 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 76.


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 76.


Revenue Code Number(s)

N/A


Misc Code

Modifier:

76: Repeat procedure by same 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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