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

Notification Issue Date:

This 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.

Title:

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

Policy #:

MA03.007b

Policy

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 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 meet any 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 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 repeated procedure or service should be reported using an applicable add-on code and appropriate number of units
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.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, repeat procedures or services on the same day in a different session by a different professional provider are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

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 May 11, 2021.

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 May 11, 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 11, 2021.

Noridian Healthcare Solutions. Modifier 77. 10/25/2018. Available At:
https://med.noridianmedicare.com/web/jeb/topics/modifiers/77. Accessed May 11, 2021.

Novitas Solutions, Inc. Modifier 77. 02/13/2017. Available At:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00092116. Accessed May 11, 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
Modifiers

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

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

6/21/2021

Version Issued Date: