Pulmonology Coding Alert

Avoid duplicate denials by identifying 94640, 32002 as repeats

Medicare considers modifiers 76 and 77 "informational only" -- meaning that they will not affect your reimbursement -- but encourages practices to use these modifiers "when appropriate." Make sure you know what that means because it can affect your pay-up.

Don't make this mistake: You may think, "If 76 and 77 have no effect on reimbursement, why bother?"

Here's your reason: Not only do correct coding guidelines direct you always to report your claims to the highest level of precision, but knowing how to apply 76 and 77 properly will also help you to know when to use other, payable modifiers.
 
Day and Procedure Must Be Identical
 
You should append modifiers 76 (Repeat procedure by same physician) and 77 (Repeat procedure by another physician) when the same physician or a different physician, respectively, must repeat an identical procedure for the same patient on the same day. The procedure involves the same CPT code, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, coding analyst with CodeRyte Inc. in Bethesda, Md.

Problem: When a payer sees the same CPT code, the reviewer or system often considers the second code a duplicate or a billing error, Jandroep says. To tell the insurer that the charge is a repeat, you use modifier 76.

Example: A patient presents with an asthma exacerbation (such as 493.02, Extrinsic asthma; with [acute] exacerbation). A pulmonologist measures peak flow and orders his staff to administer an inhaled bronchodilator treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device]). A post-treatment peak flow measurement shows that the patient's airway obstruction has improved but is still comprised. The pulmonologist orders another bronchodilator treatment. In this case, you should report 94640-76 for the repeat treatment by the same physician.  

Important: If the patient has to return later the same day for a repeat inhaled bronchodilator treatment, you should use the same CMS-1500 claim form for both sessions. If you separate the claims for the two identical, same-day services, Medicare will deny the second claim as a duplicate service, even if you append modifier 76.

Switch to 77 for Different Physician

When a different physician has to repeat a same-day procedure, you should use modifier 77 for the latter procedure. The modifier tells an insurer that a claim from a separate physician is for repeating the same procedure performed earlier in the day by another doctor and is therefore valid and not duplicative.

Modifier 77 is critical for correct reimbursement purposes. Medicare will reduce the fee on procedures appended with modifier 76, Jandroep says. But carriers will not subject modifier 77 procedures to this reduction. You're using the same CPT code, but the claim involves a different doctor represented by a different identification number.

Example: A pulmonologist performs an in-office thoracentesis with a catheter on a patient (32002, Thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]) with a pneumothorax (such as 512.1). The patient is sent home after a chest x-ray shows that the pneumothorax has been resolved after the thoracentesis.

After several hours, the patient develops recurrent chest pain and dyspnea, and he presents to the hospital where a pulmonologist from a separate practice performs another thoracentesis for a recurrence of the pneumothorax. The second pulmonologist's coder should append modifier 77 to 32002 to indicate that a different physician performed a repeat procedure.

Bill Multiple Repeats With Units, Notes

When medical necessity supports repeating a procedure more than twice, you should report the second line with modifier 76 or 77 (as appropriate) and the appropriate number of units in the units field. For instance, for three inhalation treatments by the same physician on the same day, you would report 94640, 94640-76 x 2.

If the physician repeats a service more than once (that is, if he provides the service three or more times for the same patient on the same day), after receiving the claim the insurer may require you to provide additional documentation to support the medical necessity of the repeat services. The physician's notes should clearly indicate why the patient needed these repeat procedures.

Avoid Confusion With Other Modifiers
 
Remember, modifiers 76 and 77 only apply if the repeat procedure occurs on the same day as the original procedure, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. If the repeat procedure occurs several days after the initial procedure, modifiers 76 and 77 no longer apply. But after receiving the claim, the insurer may still require you to provide additional documentation to support the medical necessity for the service's frequency.

For instance, if the patient with the asthma exacerbation returns the following day and requires another treatment, you should not use modifier 76. Similarly in the case of the repeat thoracenteses, if the in-office thoracentesis occurs on day 1 and the hospital thoracentesis occurs on day 2, modifier 77 would be inappropriate.