Pediatric Coding Alert

Question: We use modifier 76 (Repeat procedure by the same physician or other qualified healthcare professional) when we administer more than one Rocephin injection at the same visit. In addition, our practice also appends modifier 76 for subsequent injections if we administer more than one injection at the same visit. Our office manager said we should not be using modifier 76 this way. Is that accurate?

Pennsylvania Subscriber

Answer: The answer depends on the insurer, but typically, that is not an example of how modifier 76 should be used. The policy for insurer Independence Blue Cross, for example, includes the following requirements: "The events precipitating the repeat of the same procedure or service by the same provider are as follows: A change occurs in the physical status or diagnosis of the patient. Subsequent to the initial procedure or service, a different procedure or service is performed that necessitates the repetition of the initial procedure or service for diagnostic or confirmatory purposes...." (you can read this policy at http://medpolicy.ibx.com/policies/mpi.nsf/e94faffabc7b0da68525695e0068df65/85256aa800623d7a85257308004e139f!OpenDocument).

If your insurer maintains similar requirements, the examples you cited would not qualify for modifier 76. An example of what would qualify might be treatment of an epistaxis in the morning and then another in the afternoon (because the patient gets another nosebleed).

The examples you mention sound more like billing multiple units of 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) or add-on codes, depending on what’s being done. However, if your insurer approves you appending modifier 76 for this service, then you can report it to denote the split billing.