Reimbursement Policy Modifier 77
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Defines Amerigroup's reimbursement rules for procedure codes appended with modifier 77 (repeat procedure by another physician) and the documentation and billing requirements for professional and facility claims. Affects providers submitting claims to Amerigroup for covered members.
Definitions section updated by adding modifier 77.
Modifier 77 Coverage Criteria
Modifier 77 coverage criteria
Amerigroup allows reimbursement when modifier 77 is appropriately used and supported by documentation; specific exclusions apply.
Non-reimbursable uses (one or more of the following)
- When appended to an inappropriate procedure code.
- For any procedure repeated more than once.
- For the preoperative or postoperative components of a surgical procedure.
- When appended to evaluation and management (E/M) codes.
Coding and Procedure Limits
| Modifier 77 | Indicates a basic procedure or service was repeated by another physician or qualified healthcare professional; should not be appended to E/M services. |
Documentation, Submission, and Adjudication
Submit supporting documentation and meet authorization
Providers must include supporting documentation with claims when appending modifier 77. If a claim is submitted with modifier 77 without supporting documentation, the claim will not be eligible for reimbursement and providers will be asked to submit the required documentation for reconsideration. Services must also meet authorization and medical necessity guidelines.
- Documentation must be submitted with the claim when modifier 77 is used.
- If documentation is not provided the claim is not eligible for reimbursement and may be requested for reconsideration.
- Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.
Risk of claim denial, recovery, or payment adjustment
Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement to reflect the appropriate services performed.
- Amerigroup may reject or deny the claim.
- Amerigroup may recover and/or recoup claim payment.
- Amerigroup may adjust reimbursement to reflect the appropriate services and/or procedures performed.
Definitions
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