Part B Insider (Multispecialty) Coding Alert

Published on Tue Nov 09, 2004 PDF

Fine-tune your use of modifier -76 and -77 with these expert tips and examples

Don't be fooled: Repeat procedure modifiers may seem self-explanatory, but you could be overlooking some key requirements for payment.

Physicians choose to repeat procedures on patients for various reasons. When this happens, appending modifier -76 (Repeat procedure by same physician) or modifier -77 (Repeat procedure by another physician) is essential to tell the carrier your "billing is not a duplicate claim of the originally performed service, but rather an additional claim for payment of the repeated procedure," says Maggie Mac, CMM, CPC, CMSCS, consulting manager with Pershing, Yoakley & Associates in Clearwater, FL.

Difference: Differentiating between the two modifiers is the easy part. You should apply modifier -76 when the same physician repeats a procedure "on the same day or during a post-operative period," Mac says. You should apply modifier -77 when a different physician repeats the procedure, says Lisa Center, CPC, quality coordinator with Freeman Health System in Joplin, MO. 

The hard part is making sure you have the proper documentation, place of service and billing procedures necessary to secure reimbursement. Avoid denials and hang-ups with these three repeat procedure tips from the experts:

1. Check for adequate documentation before coding a repeat procedure. Carriers may require documentation to explain why the physician needed to repeat the procedure, so the physician must document medical necessity, Mac says. "CMS does not require documentation with the original [claim] submission, but may request it prior to payment," she adds.

Even though you don't need the documentation up front, you should never submit a claim unless you have proper documentation to back you up in case the carrier asks.

2. Verify an acceptable place of service before coding a repeat procedure. CMS may stipulate that the physician must perform the repeat procedure in the operating room (OR) or another place "specifically equipped for procedures," Mac says. CMS defines an OR as "the hospital OR, ambulatory surgery center (ASC) OR, cardiac catheterization suite, laser suite or endoscopy suite," she explains.

A minor treatment room cannot constitute an OR. Also, the place of service cannot be the patient's hospital room unless the physician is unable to move the patient for medical reasons, Mac says.

Exception: CMS does allow payment for repeat procedures such as x-rays, EKGs and angiograms that physicians do not perform in an OR setting, Mac says.

3. Use Block 19 of the CMS-1500 claim form to tell carriers the whole story. By appending modifier -76 or -77 you've already told the carrier you're not double billing the same claim, but instead reporting a separate and additional service. To help clarify the situation even further, however, you should explain the reason for the repeat procedure (such as comparative purposes, follow-up treatment or intervention, repeat at different intervals, etc...) in Block 19 of the 1500 form, Mac recommends.