Modifier 26 59 76 in Pathology

[rizzo9]

So I am looking for some advice...I recently have been getting claims denied as duplicates and the insurance is telling me to add the 76 modifier.

This is the scenario:

The patient had biopsies performed on the ileum, cecum, colon, rectum, sigmoid and all with the same end result of a polyp. All the specimans are labeled in the gross description to show each individual site.

These were then billed as:

88305 26
88305 26 59
88305 26 59
88305 26 59
88305 26 59

The insurance is now saying that they want the lines billed as:

88305 26
88305 26 59
88305 26 59 76
88305 26 59 76
88305 26 59 76

Is that correct??? I thought that as long as the 59 is on each line then why is there a need for the 76.

Thanks!

[gailmc]

Since 88305 has a professional component, the -76 modifier is the correct modifier.

Also since the description of 88305 has "unit of service is specimen" in it (at the beginning of the 88300 section in your CPT book) you can bill repeat services in units. Any time the CPT description has a "per" or "each" or designates a unit, we can bill those repeat services using quantity. So for this claim, I would bill 88305 -26 with a quantity of 5.

[rizzo9]

Thanks so much! I wasn't understanding why the insurance was asking for both the 59 and 76 but it makes complete sense for just the 76 modifier to be added. Thank you again for your help!!!

[clwhite]

I disagree with the use of modifier 76. Do you have any documentation that supports this? Our editing software says mod 76 is not allowed for 88305 or 88307

[dadhich.girish]

Nor does EncoderPro allow mod 76 with 88305 and 88307.

[mitchellde]

76 is not the correct modifier as this is for a repeat procedure, to be a repeat procedure it is the same procedure repeated in a different setting. That is not the case here. The 59 is the correct modifier, but why the 26? I see a need only for the 59 to indicate a distinct and separate specimen. Per or each is not an indication to use units this means each procedure as in a distinct and separate. Units would not be appropriate in this instance since each specimen is from a distinct and separate site, not multiple specimens from the same site.
If you process the specimen and provide the official interpretation then there is no need for the 26 modifier.

[RobynKing]

Coding from a pathologist point of view the -26 modifier shows that I am billing for the professtional component fo that CPT. I am however getting denied for use of 88305 -26 for the professional part of that test from BCN. Can't figure out what else they want and I am billing only one line, one unit. That is the correct billing for that code. Any ideas??