Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

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

Notification Issue Date:

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.

Title:

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

Policy #:

MA03.001b

Policy

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 by the Company.

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 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 meet one of the following criteria:
- A change occurs in the physical status or diagnosis of the individual.
- A repeat of the initial procedure or service is necessary for diagnostic or confirmatory purposes.

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 repeated procedure or service should be reported using an applicable add-on code and appropriate number of units
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 Evidence of Coverage, repeat procedures or services by the same professional provider are covered under the medical benefits of the Company's Medicare Advantage 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.

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.
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
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 May 10, 2021.

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 May 10, 2021.

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 May 10, 2021.

Noridian Healthcare Solutions. Modifier 76. 10/25/2018. Available At:
https://med.noridianmedicare.com/web/jfa/topics/modifiers/76. Accessed May 10, 2021.

Novitas Solutions, Inc. Modifier 76. 9/10/2019. Available At:
https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00092327. Accessed May 10, 2021.

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

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifier(s)

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

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

6/21/2021

Version Issued Date: