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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyAmerigroup duplicate/subsequent services Coverage …
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    CurrentAmerigroupPolicy G-06032

    Duplicate or Subsequent Services on the Same Date of Service

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    This policy governs Amerigroup's reimbursement rules for duplicate or subsequent services billed on the same date of service and the required modifier usage for reimbursement; it applies to providers submitting claims to Amerigroup Community Care.

    Policy Summary
    PayerAmerigroup
    PolicyDuplicate or Subsequent Services on the Same Date of Service
    Policy CodePolicy G-06032
    Change TypeNo material changes
    Effective Date04/11/2022
    Last ReviewMay 22, 2024
    Next Review Date
    Key ActionAllow reimbursement of a duplicate or subsequent service on the same date only when billed with the appropriate modifier; otherwise claims will be reviewed and denied.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    04/11/2022Effective date
    05/22/2024Last review
    G-06032Policy ID
    MultipleModifiers referenced

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Duplicate and Subsequent Services — Coverage Rules

    Duplicate/Subsequent and Bundled Services Criteria

    Reimbursement stance and requirements for duplicate/subsequent and bundled services billed same date:

    Duplicate or subsequent services billed on the same date are reimbursable only when billed with the appropriate modifier indicating the service was repeated or additional; otherwise claims will be denied or reviewed.
    Amerigroup will review claims billed with suspected duplicate or subsequent services. Claims determined to be duplicate or subsequent without the appropriate modifier(s) will be denied when billed on the same or separate claim.
    When a service is unbundled from a more complex or comprehensive service and billed individually on the same date of service: the claim line for the individual service will be denied through code editing if billed on the same claim; the claim will be reviewed if billed on separate claims.
    Appropriate modifiers must be used to indicate that an individual service is distinct or a repeat (examples include: 25, 59, XE, XP, XS, XU, 76, 77, AS, 91); refer to specific modifier policies for applicability.
    Claims may be rejected, denied, recouped, or adjusted if coding/billing guidelines are not followed; this policy may be superseded by provider, state, federal, or CMS contract requirements.
    Definitions: A service is a definite duplicate if elements on the claim match (member, date of service, charge amount, provider/rendering provider, type of service). A suspected duplicate exists when member, procedure code, and date of service match.

    Modifiers and Coding Guidance

    Modifiers referencedModifier
    25Significant, separately identifiable Evaluation and Management service by the same physician on the same day
    59Distinct procedural service (and related distinct modifiers XE, XP, XS, XU)
    XESeparate encounter
    XSSeparate structure
    XUUnusual non-overlapping service
    76Repeat procedure by the same physician
    77Repeat procedure by another physician
    ASAssistant at surgery who is a nonphysician
    91Repeat clinical diagnostic laboratory test
    inv-03: Modifier required for reimbursement
    RuleAn appropriate modifier must be present to reimburse a duplicate or subsequent service billed on the same date; claims determined to be duplicate or subsequent without the appropriate modifier(s) will be denied or reviewed.
    ScopeApplies when duplicate or subsequent services are billed on the same or separate claim for the same member and date of service.
    Action on noncomplianceClaims billed without the required modifier(s) will be denied or subjected to review and potential recoupment or adjustment.
    Related guidanceRefer to the Related Coding/modifier-specific policies (e.g., Modifiers 25, 59, XE/XS/XU, 76/77, AS, 91) for applicability and appropriate usage.

    Provider Billing Requirements

    Note

    Modifier required to reimburse duplicate/subsequent services

    Amerigroup allows reimbursement of a duplicate or subsequent service provided on the same date of service if billed with an appropriate modifier; claims will be reviewed and denied if the duplicate/subsequent service is billed without the required modifier.

    • Reimbursement permitted when billed with an appropriate modifier indicating the service was repeated or additional.
    • Claims will be reviewed when billed with suspected duplicate/subsequent services and denied if determined duplicate/subsequent without the appropriate modifier(s), whether on the same or a separate claim.

    Key Definitions

    inv-05: Duplicate Services
    Definite duplicateA service is a definite duplicate if some or all of these claim elements match: member, date of service, charge amount, provider/rendering provider, and type of service (procedure or revenue codes).
    Suspected duplicateA service is a suspected duplicate if the member, procedure code, and date of service match on the claim.
    Determination useThese matching-element criteria are used to identify duplicates for review, denial, or coding edits under the policy.
    Policy Summary
    PayerAmerigroup
    PolicyDuplicate or Subsequent Services on the Same Date of Service
    Policy CodePolicy G-06032
    Change TypeNo material changes
    Effective Date04/11/2022
    Last ReviewMay 22, 2024
    Next Review Date
    Key ActionAllow reimbursement of a duplicate or subsequent service on the same date only when billed with the appropriate modifier; otherwise claims will be reviewed and denied.
    SourceLink
    On This Page
    Duplicate and Subsequent Services — Coverage RulesModifiers and Coding GuidanceProvider Billing RequirementsKey Definitions