CurrentAnthemPolicy G-06032

Duplicate or Subsequent Services on the Same Date of Service

This policy governs Anthem Blue Cross and Blue Shield New York Medicaid reimbursement for duplicate or subsequent services provided to the same member on the same date of service, specifying modifier usage and claim review/denial practices. It applies to providers submitting claims under Anthem NY Medicaid.

Policy Summary

PayerAnthem

PolicyDuplicate or Subsequent Services on the Same Date of Service

Policy CodePolicy G-06032

Change TypeNo material change

Effective DateApr 11, 2022

Next Review Date

Key ActionProviders must bill duplicate or subsequent services with appropriate modifier(s) to be reimbursed; claims without the appropriate modifier(s) will be reviewed and denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Allows reimbursementpolicy stance

Denied without modifierdenial condition

Multiple listedmodifiers enumerated

05/22/2024last approval

Coverage for Duplicate, Subsequent, and Bundled Services

Duplicate/Subsequent/Bundled service criteria

Coverage and claim handling for duplicate, subsequent, and bundled services on the same date of service.

Anthem allows reimbursement of a duplicate or subsequent service provided on the same date of service if billed with an appropriate modifier, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Reimbursement of duplicate or subsequent services is based on correct usage of the modifiers listed in Related Coding; claims billed with suspected duplicate or subsequent services will be reviewed.

Claims will be denied for services determined to be duplicate or subsequent without the appropriate modifier(s) 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.

Policy Summary

PayerAnthem

PolicyDuplicate or Subsequent Services on the Same Date of Service

Policy CodePolicy G-06032

Change TypeNo material change

Effective DateApr 11, 2022

Next Review Date

Key ActionProviders must bill duplicate or subsequent services with appropriate modifier(s) to be reimbursed; claims without the appropriate modifier(s) will be reviewed and denied.

SourceLink

On This Page

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Modifiers, Code Editing, and Billing Codes

Modifiers relevant to duplicate/subsequent and bundled servicesModifier

25	Significant, separately identifiable Evaluation and Management service by the same physician on the same day of the procedure or other service.
59	Distinct Procedural Service.
62	Co-surgeons.
66	Surgical teams.
76	Repeat procedure by the same physician.
77	Repeat procedure by another physician.
80	Assistant at surgery providing full assistance to the primary surgeon.
81	Assistant at surgery providing minimal assistance to the primary surgeon.
82	Assistant at surgery, when a qualified resident surgeon is not available to assist the primary surgeon.
91	Repeat clinical diagnostic laboratory test.

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Same-claim code editing — Individual service line will be denied through code editing if unbundled and billed on the same claim.

Policy actionIndividual service line will be denied through code editing if an unbundled service is billed on the same claim as the more complex/comprehensive service.

Separate-claim handlingIf the unbundled individual service is billed on a separate claim, the claim will be reviewed to determine appropriateness for reimbursement using modifier guidance.

Modifier guidanceModifiers that may indicate an individual service is distinct from a more comprehensive service include: 25, 59, 62, 66, 76, 77, 80, 81, 82, 91, AS, GG, GH, XE, XP, XS, XU (refer to related modifier policies for state applicability).

Billing Requirements and Claim Review

Prior Authorization

Bill duplicate/subsequent services with the appropriate modifier(s)

Providers must bill duplicate or subsequent services with the appropriate modifier(s) to be reimbursed. Anthem will review claims billed with suspected duplicate or subsequent services and will deny services determined to be duplicate or subsequent when not billed with the appropriate modifier(s).

Use modifiers listed in the Related Coding section to indicate a repeated or additional service.
Denials may occur whether the duplicate/subsequent service is on the same claim or a separate claim if the appropriate modifier(s) are not present.

Definitions

Duplicate Services — Definition and criteria

Definite duplicate — criteriaA service is a definite duplicate if some or all of these claim elements match: member, date of service, charge amount, provider of service/rendering provider, or type of service based on procedure or revenue codes.

Suspected duplicate — criteriaA service is considered a suspected duplicate when the member and procedure code on the claim match.

PurposeUsed to identify claims that may be denied or require further review when duplicate billing is detected for the same member on the same date of service.

Subsequent service — Definition

DefinitionA subsequent service is a medically necessary service that is performed or provided for the same member more than once on the same date of service.

Reimbursement implicationReimbursement of subsequent services is contingent on correct modifier usage and review per policy; services without appropriate modifiers may be denied.

Related guidanceRefer to modifier-specific policies and the policy's modifier list to determine when repeat services on the same date are distinct and payable.