UnitedHealthCare Modifier 76 (repeat surgical procedure) and Modifier 79 in a postop

ellzeycoding

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UHC denies both Mod. 76 (repeat surgical procedure) WITH Mod. 79 in a postop period

Scenario:

United Healthcare doesn't like modifier 76 for a repeat surgical procedure when billed in a postop period of a previous unrelated service which also requires modifier 79

For example...

UHC has no problems billing this...

11401
11401 -76 (repeat excision)

No problem billing this...

11401 -79 (excision billed in a 10 or 90 day postop period of a previously unrelated procedure)


UHC doesn't like this.

11401 -79
11401 -76 -79 (they don't like 76 and 79 on the same line)

The second is excision is a repeat procedure and is also in a postop period for a previous unrelated service. Both modifiers are appropriate. They will pay the first, but not the second.

What's the best way around this? Modifier 59 isn't appropriate as they aren't bundled procedures according to the NCCI edits.

There are other carriers that don't like 76 and 79 together, but UHC is a biggie.

What say ye?
 
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thomas7331

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Different payers, and even different payer systems within a payer, will have their quirks when getting into complicated coding situations like this, and sometimes you end up just having to appeal the denials. However, I believe that the modifier 59 or XS would be more appropriate and, in my experience, is more likely to resolve the issue. 76 is for a 'repeat', which is usually for something like an EKG or X-ray which is the exact procedure done again on the same day due to a change in patient condition. An excision done on a different lesion is not a 'repeat' procedure but rather a 'distinct' procedure - it's an entirely different and separate procedure that just happens to be coded with the same CPT. Modifier 59 is not limited to bundled codes, and this situation actually fits the CPT definition of 59 better than 76. I've worked with several practices and all have preferred the 59/XS modifiers for this situation and have had relatively few problems with denials.
 

ellzeycoding

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Thomas.

Thanks for the response.

I have to partially agree and disagree on many points.

Many carriers, including CMS limit modifier 59 to bundled pairs in the NCCI listing.

A lot changed for “Medicare” starting in 2013.

As of July 2013, modifier 59 can only be used to unbundle codes relative to the National Correct Coding Initiative listings which appear as code pairs.

Source:

https://www.aad.org/File%20Library/Unassigned/DCC_Fall_2013.pdf

“Q. I just received a Medicare denial as duplicate procedure when billing for two excisions, 11401 listed on two separate claim lines, one with Modifier 59. What’s wrong?

A. Effective July 1, 2013, Modifier 59 can only be used, when medically necessary, to unbundle a procedure code that has been bundled related to the National Correct Coding Initiative (NCCI). Claims billed with the same procedure code two or more times for the same date of service, should be submitted with an appropriate repeat procedure modifier. Rather than Modifier 59, Modifier 76 should be used to report a service or procedure that was repeated by the same practitioner subsequent to the original service or procedure. If multiple same lab or pathology services are reported, Modifier 91 is used to report repeat laboratory tests or studies performed on the same day on the same patient.”


Many carriers consider the use of modifier 59 inappropriate if they do not appear as a bundled pair in the NCCI listings. A code is never bundled with itself or appearing as a code pair in the NCCI listings.

For example.. here is WPS Medicare’s policy on modifier 59…

https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-59

Inappropriate Usage

Code combination not appearing in the NCCI edits”



Modifier 76

Dermatologists use modifier 76 for “like” or repeat surgical proceduures (when not billable in units) for DECADES. It’s been taught this way by the American Academy of Dermatology and coding experts for ever. Most carriers accept modifier 76 for repeat surgical procedures without question. There are a few that don’t recognize modifier 76 on surgical procedures. For those carriers, you bill without 76 and add an instruction in box 19.

Example… WPS Medicare is one of the odd-balls that doesn’t recognize modifier 76 for repeat “surgical procedures”. Rather than use modifier 59 (which they say is incorrect two identical codes don’t appear together in the CCI, they say omit a modifier all together and use Box 19 to indicate the repeat procedure.

https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-76

Additional sources of information from the AAD on the acceptable use of modifier 76…

Top-right of page 6…

https://www.aad.org/File Library/Main navigation/Practice tools/Coding resources/Derm Coding Consult/DCC_Fall-2014.pdf

Right-side or page 4…

https://www.aad.org/File Library/Main navigation/Member resources and programs/Publications/DCC/DCC_Spring_2015.pdf


Yes, there are are a bunch of carriers that will prefer modifier 59(XS) instead of 76. The inconsistencies are frustrating.



I know we’re talking about UnitedHealthcare here...


My original post shows that UHC does indeed recognize modifier 76 for repeat (or like) surgical procedures. They pay without issue or appeal in my example (and many, many surgical procedures). I see it on EOBs all the time.

They also, or course, pay with modifier 79 for unrelated services within a global period.

They have an issue when combined on the same line. Usually several appeals will resolve the issue.

So I was hoping someone can show me a better way (verification with an EOB would be even better).

Regarding modifier 59/XS as the way, I have issues in regards to UHC

UHC published their CCI Editing Policy referencing modifier 59 as of late 2016. It gives a starting point for an argument.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/ReimbursementPolicies/CCI_2017A.pdf

Here is UHC’s Rebundling policy stating that they follow Medicare’s NCCI guidelines

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/ReimbursementPolicies/Rebundling_2016A.pdf

11401 and 11401 don’t appear anywhere together in column I and column II

So my argument is that modifer 59 or XS for a repeat or “like” surgical procedure goes against the CMS guidelines for the NCCI which state that only codes that appear in the NCCI listings as bundled pairs can appropriately be used with modifier 59.

Again, appeals (sometimes multiple) will fix this.

I know this is an unusual situation, but I think the use of both modifiers as acceptable with UHC is proven. The combination causes a system failure.

Thanks again, Thomas for your input. Much appreciated.

Anyone else have suggestions or thoughts?
 

thomas7331

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Hi Karl, you and I have met at one of your conferences, didn't realize it was you on the original post. Hope you're doing well.

Granted I have never worked in one of the WPS jurisdictions, and not to belabor the point, but I think it's incorrect to state that CMS guidelines for NCCI only allow modifier 59 for bundled pairs - I have never seen such a thing in writing from CMS. I believe the AAD 2013 Q&A may be either incorrect or outdated on this point - their CMS reference to the section on duplicate check logic does not state anywhere that modifier 59 is not appropriate or not allowed outside of the NCCI code pairs. As I mentioned on my last post, I've worked for many years with a number of providers in multiple states who have used modifier 59 effectively this way - many of whose billing has been reviewed extensively by expert coders and payer auditors - and this has never been cited as an issue.

I don't know if this would resolve your issue with UHC or not, but I think it would be worth a try. In any case, UHC is a large payer with many types of plans and claims system, and with a human error factor too, so I think it's to be expected that there would be inconsistency and probably not a single solution that will take care of it in all cases. I'll look forward to seeing if anyone else has any input on this.
 
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