Reimbursement Policy — Modifier 76
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This policy governs Amerigroup's reimbursement rules for procedures or services reported with modifier 76 (repeat procedure by the same physician) and outlines when reimbursement is allowed or disallowed for professional and facility claims.
Updated Definitions section by adding modifier 76.
Coverage Criteria for Modifier 76
Modifier 76 coverage criteria
Covered or denied when the following conditions are met:
ALL of the following
- Modifier 76 appended.
- Supporting documentation submitted with the claim.
- Clinical review for professional services (except radiology) as applicable.
ALL of the following
- Modifier 76 appended.
- Supporting documentation submitted with the claim.
- If surgical, reimbursement applies to the surgical component only and is limited to a total of two procedures.
Non‑reimbursable uses (any of the following)
- Modifier 76 is appended to an inappropriate procedure code.
- Any procedure is repeated more than once (i.e., more than two repeated surgical procedures are not reimbursable).
- Modifier 76 is used for the preoperative or postoperative components of a surgical procedure.
ALL of the following
- If supporting documentation is not submitted with the claim, the claim will be ineligible for reimbursement.
- Providers will be asked to submit required documentation for reconsideration.
Coding and Reimbursement Limits
| Modifier 76 | Indicates that a procedure or service was repeated by the same physician or other qualified healthcare professional subsequent to the original procedure or service. Should not be appended to an E/M service. |
Provider Billing and Documentation Requirements
Submit supporting documentation with claims using modifier 76
Providers must submit supporting documentation for the use of modifier 76 with the claim; if a claim is submitted with modifier 76 without supporting documentation, the claim will not be eligible for reimbursement and providers will be asked to submit the required documentation for reconsideration of reimbursement.
- Supporting documentation must be submitted with the claim to be eligible for reimbursement.
- If documentation is not provided, the claim will be ineligible and providers will be asked to submit documentation for reconsideration.
Confirm authorization and medical necessity before billing
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; failure to meet applicable coding/billing guidelines or reimbursement policies may result in claim rejection, denial, recovery, or reimbursement adjustment.
- Ensure services meet authorization and medical necessity requirements for the procedure, diagnosis, and member's state of residence.
- Use proper CPT, HCPCS, and/or revenue codes and ensure services are fully supported in the medical record and/or office notes.
- Noncompliance with coding/billing or reimbursement policies may lead to claim rejection, denial, recoupment, or adjusted reimbursement.
Definitions
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