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Repeat Surgical Procedures

Policy ID: NDRP-Surg-010
Section: Surgery
Effective Date: July 01, 2018
Last Reviewed: October 03, 2019

Description:

The policy provides guidelines for the reimbursement of services with modifiers 76 and 77 for professional providers.

Definitions:

Modifier Description
76 Repeat procedure or service by same physician or other qualified health care professional
77 Repeat procedure by another physician or other qualified health care professional

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.

Cross-Reference:

History:

date Updates
10/03/19 Added Limitations and Exclusions, Disclaimer and History.

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.