Practice Management Alert

You can stop denials in their tracks with modifiers -76 and -77

You've heard it a thousand times before: Payment depends on good documentation. But that's not all you need in order to secure reimbursement for repeat procedures - you must also use appropriate modifiers.

Appending modifier -76 (Repeat procedure by same physician) or modifier -77 (Repeat procedure by another physician) is essential when a patient receives a repeat procedure. Differen-tiating between the two modifiers is the easy part, but you need to be aware of the nuances for using each one.

-76: Use modifier -76 when the same physician "repeats a procedure on the same day or during a postoperative period," says Maggie Mac, CMM, CPC, CMSCS, consulting manager with Pershing, Yoakley & Associates in Clearwater, Fla.

Example: A patient with respiratory distress (for instance, 786.09, Symptoms involving respiratory system and other chest symptoms; dyspnea and respiratory abnormalities; other) presents to a pulmonologist and requires two chest x-rays in the office during the course of the same day. If the same physician reads both x-rays, you would report 71010 (Radiologic examination, chest; single view, frontal) and 71010-76.

-77: Apply modifier -77 "when a different physician repeats a procedure on the same day or during a post-op period," Mac says. So based on the example above, if two different physicians ordered the two chest x-rays during the same day, you would report 71010 and 71010-77 to indicate that a different physician ordered the second procedure.

Note on reimbursement: Both modifier -76 and -77 have an RVU of "1" - so appending this modifier to a code will not affect your reimbursement. For example, in the scenario above, you could expect full payment for each 71010 code you report.

Know the Nuances of -76, -77

Documentation: As usual, 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. So don't hassle with sending documentation right away - just know that the carrier may ask.

Place of service: 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 adds. 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, she 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.

Block 19: Modifiers -76 and -77 tell carriers that you are not billing "a duplicate claim of the originally performed service, but rather an additional claim for payment of the repeated procedure," Mac says. To help clarify even further, you should explain the reason for repeat procedures (such as comparative purposes, follow-up treatment of intervention, repeat at different intervals, etc.) in Block 19 of the CMS-1500 claim form, she says.