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Modifier for two visits on same day

  1. #11
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    Exam Training Packages
    http://www.trailblazerhealth.com/Pub...ntServices.pdf

    Page 11 - My understanding is if the condition is the same you combine the time - different append 76.

  2. #12
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    I see where it says it but that is for trailblazer and is not CMS. Also per HIPAA, the codes and modifiers all have the same definitions regardless of the payer. I just cannot see how in any way this fits the definition of the 76 modifier for a repeat procedure/service. Since the dx is different then the same service cannot be repeated. And in the federal register it is stated this modifier is not for E&M codes.

    Debra A. Mitchell, MSPH, CPC-H

  3. #13
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    North Carolina
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    Physicians in Group Practice
    • Physicians of the same specialty in the same group practice must bill and be paid as a single physician.
    • If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. (Refer to instructions for use of the 76 modifier.)
    Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

    • Use the 76 modifier when billing for separate office or outpatient E/M visits that occur on the same date of service (only for codes 99211–99215) by the same physician/practitioner.
    • Each service should be clearly documented.
    Use the 76 modifier to indicate a separate encounter occurred on the same date of service when separate services are billed. Do not use the 76 modifier for the initial visit.

    Example of Proper Usage
    A patient visits the physician on Wednesday morning for a bladder infection. She is treated and sent home. That same afternoon, the patient returns to the physician’s office with a twisted ankle. Each service should be reported with the appropriate level of E/M service with the 76 modifier added to the second visit for the twisted ankle.



    Talk about speaking out of both sides of the mouth. This is definitely carrier discretion...

  4. #14
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    I understand what you are saying. I have yet to use this modifier in this situation and do not know how it would pay. The publication is by TrailBlazer our FI but based from CMS guidelines. They should not be different.

  5. #15
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    North Carolina
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    Unfortunately or fortunatley (depending on your view) your MAC can create guidelines applicable to your locality. This can become burdensome when you refer to the CMS manuals for guidance; yet, your local carrier states the complete opposite. That's why...when giving advice...I direct them to CMS guidance but always suggest to contact their local carrier for their view. Here is an example of why this is important to do this...

  6. #16
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    Rebecca - Do you have some ref links that talks about the using mod 76?

  7. #17
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    North Carolina
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    My carrier...

    April 15, 2008

    Inappropriate Use of Modifiers 76 and 77

    We have seen an increase recently in use of the -77 and -76 modifiers with E&M services to bypass edits related to concurrent care by two physicians of the same specialty on the same day. Communication with CMS Central Office has confirmed that this is an inappropriate use of these modifiers. Although the CMS Manual system doesn't clearly state this, per se, the intent is and always has been for these modifiers to apply only to procedures, not to E&M services. Revised language making this clear will be coming out in a Manual revision later this year, and a forthcoming NCCI update will also make this clear. In the meantime, providers are encouraged to not append the 76 and 77 modifiers to claims for E&M services. Future audits of such inappropriate use of the modifiers on claims will likely result in recoupment of monies incorrectly paid.

    http://www.cignagovernmentservices.c.../cope7413.html

  8. #18
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    Columbia, MO
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    Here is something from the AMA 2008 for starters:
    Using modifier 76
    Modifier 76 (repeat procedure or service by same physician) should be used to indicate that a procedure or service was repeated subsequent to the original procedure. According to the AMA CPT Manual, modifier 76 was revised to designate the intent of the procedure to be used to report repeat procedures, as well as repeat services provided by the same physician.

    As indicated in the definition of modifier 78, modifier 76 is not restricted to procedures performed on the same day. Modifier 76 is applicable to both surgical and diagnostic procedures and services that are repeated. It should not be used for planned or anticipated subsequent or staged procedures or related unplanned procedures (such as for complications).

    If, for example, a physician reduces a distal radius fracture in the office on May 15 and the reduction is lost so that the fracture must be reduced a second time on May 22, the physician would report CPT code 25605 (Closed treatment of distal radial fracture [eg, Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation) for the May 15 visit and 25605-76 to indicate a repeat reduction for the May 22 visit.

    Source: CPT Changes: Insiders Edition 2000-2008.
    I think that two visits on the same day for different problems does not meedt the definition.

    Debra A. Mitchell, MSPH, CPC-H

  9. #19
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    Thats the one I was looking for! Thanks Rebecca!

    Debra A. Mitchell, MSPH, CPC-H

  10. #20
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    The post from Soundar says the visits were for unrelated problems. According to the post from Rebecca (I copied her reference from CMS below), it looks like both should be billable. I would try putting the times of the visits in the comment field or send the office notes.


    Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level

    http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

    Michele R. Hayes, CPC, CEMC, CGIC

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