Getting paid for repeat procedural services — What is the secret ingredient?

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Coding & Reimbursement, March 1, 2022

Dermatologists and non-physician clinicians (NPCs)* often come across clinical encounters requiring the use of modifiers to report multiple identical services and/or procedures performed on the same patient by the same provider on the same date of service (DOS).

Modifiers consist of either two numerical, alphabetical, or alphanumerical characters that accompany Current Procedural Terminology or Healthcare Common Procedure Coding System (CPT/HCPCS) codes and provide a means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers also enable the dermatologist or NPC to effectively respond to payment policy requirements established by health claim payer entities.

Although the use and application of modifiers may vary from payer to payer, they are frequently recognized during health care claims processing, which could make the difference between full claim reimbursement and/or incurring payment reductions or even denials.

Protect your practice’s bottom line

Multiple identical services provided to an individual patient reported with the same AMA CPT^® code on the same day by the same provider may be denied as duplicate claims if the Medicare Administrative Contractor (MAC) or health insurance company cannot determine that the services were performed more than once on the same day or during the same encounter.

To prevent unwarranted claim denials, it may be helpful to append modifier 76 (considered the secret ingredient) to the identical, repeated service/procedure code(s).

General use of modifier 76

When multiple identical services are rendered and reported with the same CPT code, the dermatologist/NPC can appropriately relay this information to the payer by appending modifier 76. As indicated in the AMA CPT coding manual, modifier 76 is used to report repeat procedure or service by same physician or other qualified health care professional: It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.

Appropriate use of modifier 76

For successful and appropriate reporting of modifier 76:

• Report when a distinct, identical surgical procedure (same CPT code as the first procedure) is performed by the same dermatologist or NPC on the same date of service.

• Append to procedure codes that cannot be quantity billed.

  • For example, after an excision in the morning, the wound is closed with an intermediate repair. However, the patient returns to the office in the afternoon stating the wound was strained causing the stitches to rip open. The dermatologist then closes the wound again with an intermediate repair, documents the encounter, and reports the same CPT code like the earlier closure and appends modifier 76.

• Report each service code on a separate line, using a quantity of 1, and append modifier 76 to the subsequent identical procedures reported with the same CPT code.

• Bill all services performed on one day on the same claim.

• Ensure the documentation supports the use of the modifier.

Inappropriate use of modifier 76

Avoid the following misuse of modifier 76:

• Do not append modifier 76 to every line of service on the claim form.

• Do not append modifier 76 to:

  • staged surgical procedure code; see modifier 58 instead.

  • unplanned return to the operating room; see modifier 78 instead.

  • unrelated procedure or service; see modifier 79 instead.

• Do not append modifier 76 to repeat services due to equipment/technical failure.

• Do not append modifier 76 to repeat laboratory services; see modifier 91.

• Do not append modifier 76 to services repeated for quality-control purposes.

• Do not append modifier 76 to a service or procedure provided more than once due to unusual event circumstances.

  • For example, unusual circumstances caused by discontinuation of the procedure because the physician performing the initial service believes another physician’s expertise (within the same group) is needed. The service is performed on the same date and should be reported with the same identical CPT code.

• Do not report modifier 76 with "add-on" codes; denoted in CPT with a “+” sign.

  • If a service defined as an "add-on" code is repeated or provided more than once (based on description) on the same day by the same provider, report the "add-on" code on one line with a multiplier in the unit field to indicate how many times the service was performed (e.g., four tangential biopsies reported with CPT codes 11102 x 1; +11103 x 3).

Pitfalls that can cause claim denial

There are a few common errors to avoid when using modifier 76 on two or more of the same procedure code for the same date of service that must be avoided.

1. Failing to list the identical service/procedure codes on separate claim lines.

2. Failing to append modifier 76 to the second procedure code to indicate a repeat service/procedure.

3. Not providing a short explanation (e.g., indicating the same size but different lesion or anatomical location treated using the same technique). For example, destruction of three malignant lesions that are reported with the same size and location CPT code set are as follows:

Including a short explanation for the multiple repeat services in the comment field (box 19 of the CMS 1500 form) of the claim helps the payer to understand the reason modifier 76 was used two (or more) times for the same CPT code on the same date of service.

For example, indicate that the second and third lesions treated were located on different anatomical locations, even though the procedure code reported, based on lesion size and anatomical location, is the same for all lesions treated.

Example CMS 1500 with modifier 76

Note: Do not append modifier 76 on the first service line reported on the same date of service.

Appealing denied claims

Expect a denial with a remark code indicating you have duplicate claims if identical services are reported without the appropriate modifier for the same date of service. Before you resubmit the claim with a different modifier, for example modifier 59 (considered a trigger for claim audits), consider the “secret ingredient” (modifier 76) instead for identical services and/or procedures reported more than once on the claim form.

To ensure correct processing of your resubmitted claim:

• Submit services on one claim using the "Days/Units" fields and appropriate modifier.

• Be sure the correct modifiers are included on the claim when multiple identical services are submitted to identify these services as separate services and not duplicate billing of the same service.

For more information on the appropriate use of modifiers, visit the Academy's Practice Management Center.

* The AADA uses the term non-physician clinician (NPC) to provide greater clarity when services/procedures are provided and reported by a provider such as a PA or NP. Where appropriate, this term is used in place of the American Medical Association’s QHP acronym, which is also used by CMS and private payers, as NPC more clearly conveys these providers’ credentials and differentiates them from physicians.

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