General Surgery Coding Alert

Sometimes your surgeon or another surgeon repeats a procedure on the same date of service, and that can get you in trouble if you don’t know how to indicate to your payer that you’re billing for two separate, medically-necessary procedures.

Read on for tips about how to handle this situation, provided by Michelle Coleman, CPC, and Arlene Dunphy, CPC, provider outreach and education consultants from the Medicare Administrative Contractor (MAC) National Government Services (NGS) in a recent webinar “How to Avoid Duplicate Claim Denials.”

Beware These Problems

“When a claim comes into the system, we compare elements to identify an exact duplicate,” Coleman said. These elements include:

• Medicare Beneficiary Identifier (MBI) or provider number
• From date of service
• Through date of service
• Type of service
• Procedure code
• Place of service
• Billed amount

If the system already has a claim that’s processed or is in process with the same elements, it’s either going to be held up, suspended, or be denied as a duplicate, Coleman explained.

Count the cost: Submitting duplicate claims can cause several problems, such as delaying payment, increasing administrative costs to the Medicare program, being identified as an abusive biller, or resulting in an investigation for fraud if a pattern of duplicate billing is identified, Coleman said.

“We get a report once a month of the top 100 providers who have submitted the most duplicate claims,” according to Coleman. “We review the report, and if you are on that report, you could be getting a call from the provider outreach and education department. We try to work with the provider, and the majority of the time, it’s a system glitch the provider had no idea was happening. So, they can either go to their vendor or their clearinghouse and have the problem rectified.”

However, Coleman added that if they see you are still submitting duplicate claims after the provider outreach department has spoken to you, you could be identified as an abusive biller and be investigated for fraud.

Append Repeat Modifiers Properly

When you are submitting claims for multiple instances of services or procedures, your claims should include an appropriate modifier to indicate that the service or procedure is not a duplicate, Dunphy said.

Take a look at some common repeat modifiers you might use:

Modifier 76: (Repeat procedure or service by same physician or other qualified health care professional)

Appropriate uses for modifier 76:

• For the same procedure or service performed on the same day
• On a procedure code in which quantity or number of units cannot be billed
• On the first line, and then again with modifier 76 (second line item — second line item will have the appropriate quantity billed amount)

Inappropriate uses for modifier 76:

• For each line of service
• For repeat services due to equipment or other technical failure
• For services repeated for quality control purposes
• With an evaluation and management (E/M) code

Modifier 77: (Repeat procedure by another physician or other qualified health care professional)

Appropriate uses for modifier 77:

• For the professional component of an X-ray or EKG procedure when a different physician repeats the reading because another physician’s expertise is needed or when the patient has two or more tests, and more than one physician provides the interpretation and report
• For billing for multiple services on a single day and the service cannot be quantity billed

Inappropriate uses for modifier 77:

• When billing for multiple services bundled based on National Correct Coding Initiative (NCCI) edits
• With an E/M code

Follow 6 Tips to Avoid or Fix Denials

Coleman shared the following helpful tips you can follow to avoid or resolve duplicate-claim denials in your practice:

• Tip 1: Check your remittance advice for the previously posted claim.
• Tip 2: Verify the reason the initial claim was denied.
• Tip 3: Don’t just resubmit to correct a denial.
• Tip 4: Use the interactive voice response (IVR) or NGSConnex to check on current claim status.
• Tip 5: Allow 30 days from the receipt date before addressing a concern.
• Tip 6: Make sure your billing service/clearinghouse is waiting the appropriate time frame.