Policy
Claims for multiple and/or identical services provided to a member, on the same day, may be denied as duplicate if BCBSND cannot determine that the services have been performed more than one time. Filing claims properly the first time with appropriate modifiers, when applicable, will reduce rejections.
Providers must use the appropriate modifiers when billing for repeat services:
- Modifier 76 indicates that a procedure or service was repeated subsequent to the original procedure or service by the same provider on the same patient on the same date of service or within the post-operative period.
- Modifier 77 is reported when the same procedure or service has been performed by a different provider to the same patient on the same date of service or within the post-operative period of the original procedure.
- Modifier 91 is used to report repeat laboratory tests on the same date of service to obtain multiple test results. Modifier 91 should not be used when tests are repeated to confirm initial test results due to testing problems with equipment or specimens or with codes that describe a series of test results, such as glucose tolerance or evocative suppression tests.
Note: Do not append modifiers 76 or 77 to an Evaluation and Management (E/M) service. Refer to the Modifiers 25, 27, 59, FT, XE, XP, XS & XU Policy.
Claim and/or line-item rejections will be applied if:
- Identical duplicate services are submitted for the same date of service, by the same performing provider without the use of an appropriate modifier.
- Identical duplicate services are submitted for the same date of service, by another performing provider with the same specialty within the billing group without the use of any modifier.
The sole fact that a procedure or service must be repeated after the original does not warrant additional payment above the allowance for the original procedure or service being reported.
Coding and Billing Guidelines
To avoid duplicate claim and/or line-item rejections providers should:
- Submit all services for the performing provider using appropriate units and modifiers based on the medical documentation on one claim.
- Ensure appropriate modifiers are submitted on the claim when:
- Performing provider renders multiple identical services on the same date of service for the member.
- A different performing provider with the same specialty renders the identical service on the same date of service for the member.
- Repeat clinical diagnostic laboratory tests are rendered on the same date of service for the member.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity.
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
