Description:
The policy provides guidelines for the reimbursement of services with modifiers 76 and 77 for professional providers.
Definitions:
Modifier
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Description
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76
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Repeat procedure or service by same physician or other qualified health care professional
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77
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Repeat procedure by another physician or other qualified health care professional
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Policy:
Use modifier 76 to indicate 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.
Note: Do not append modifiers 76 or 77 to Evaluation and Management (E/M) services.
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.
Limitations and 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, 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.
History:
Date
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Updates
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10/03/19
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Added Limitations and Exclusions, Disclaimer and History.
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