We have billed the following procedures in the following format: 17262, 17262 51-76, 17262 51-76, 17262 51-76. CMS pays the procedures 1 and 2 and rejects the last two. We appeal with records and they reject again as a duplicate. We call and a representative states change the units. Fast forward to billing same procedures for another patient to Anthem. Anthem rejects and states inappropriate coding. Provider must use appropriate modifiers for multiple procedures. They stated that 76 modifier states that it is a duplicate procedure for same body part and it was not. This is in the 3rd appeal as we have sent the records twice. We are now going to send the records again with a copy of the CPT coding guidelines for the modifier which does NOT state duplicate procedure for same body part. Appeals sent it back to claims review stating that it was not coded correctly to which claims review denied for inappropriate coding. Has anyone else run into the issue of carriers rewording the guideline and denying?? Thanks in advance for ANY help!
Modifier 76 is incorrect in this case. If your provider is destroying a malignant lesion in one area that lesion is gone, so doing the same procedure in another area is not a repeat procedure. It is the same CPT but not the identical procedure. Depending on the payer you will either bill it with units or with 51-59 on each subsequent 17262 after the first.
An identical procedure to justify modifier 76 would be a chest x-ray or an EKG done more than once on any given day. That is when you use 76 or 77.
In response to the other situation mentioned by another member, when one study is with contrast and one without, this cannot be modifier 76 or 77 They are not repeat procedures. If both were done with contrast or both done without contrast, yes 76 or 77 is correct.
Hope this helps somewhat.
