CurrentAnthemPolicy G-06018

Modifier 76 reimbursement

Policy governing Anthem reimbursement rules for using Modifier 76 (repeat procedure by same physician) on professional and facility claims, including reimbursable vs non-reimbursable uses and documentation requirements.

Policy Summary

PayerAnthem

PolicyModifier 76 reimbursement

Policy CodePolicy G-06018

Change TypeTemplate and reference updates

Effective Date10/03/2018

Next Review Date

Key ActionSubmit supporting documentation with claims billed using Modifier 76; claims without documentation will be denied.

SourceLink

POLICY UPDATE CHANGES

Updated policy template; removed 'Repeat Procedure by the Same Physician' from the policy title; removed 'subsequent' definition.

Updated Reference and Material Related Policies sections.

100%nonsurgical repeated procedures

100% up to 2repeated surgical procedures (surgical component)

Deniedno supporting documentation

E/M, lab, pre/post-opnot reimbursable with

Modifier 76 Coverage Criteria

Modifier 76 coverage criteria

Covered when ALL of the following criteria are met:

Modifier 76 indicates the procedure or service was repeated by the same physician.

The repeat service is billed subsequent to the original procedure for professional provider claims OR on the same date as the original procedure for facility claims.

ALL of the following

ONE of
- Nonsurgical procedure or service: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate.
- Surgical procedure: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate for the surgical component only, limited to a total of two surgical procedures (assistant surgeon and multiple-procedure reductions may apply).

Policy Summary

PayerAnthem

PolicyModifier 76 reimbursement

Policy CodePolicy G-06018

Change TypeTemplate and reference updates

Effective Date10/03/2018

Next Review Date

Key ActionSubmit supporting documentation with claims billed using Modifier 76; claims without documentation will be denied.

SourceLink

On This Page

Modifier Usage and Coding Rules

Covered codesmixedCovered

Modifier 76

Repeat procedure or service by same physician

Excluded / Not reimbursable codesmixedNot Covered

E/M codes	Evaluation and management (E/M) codes
Laboratory codes	Laboratory codes
Preoperative component	Preoperative component (not reimbursable with Modifier 76)
Postoperative component	Postoperative component (not reimbursable with Modifier 76)
Any procedure repeated more than once	Any one procedure repeated more than once (not reimbursable)

Repeated surgical procedure limit

Reimbursement rateSurgical component reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate, limited to a total of two surgical procedures

ScopeApplies when a surgical procedure is repeated by the same physician on the same date for facility claims (unless contracts require otherwise)

LimitsOnly the surgical component is reimbursed at the stated rate; assistant surgeon and multiple procedure rules and fee reductions may still apply

Professional servicesProfessional services (other than radiology) are subject to clinical review for consideration of reimbursement

Documentation requirementProviders must submit supporting documentation with the claim; claims without documentation will be denied and may be reconsidered upon submission of required documentation

Documentation & Clinical Review Requirements

Documentation Required

Submit supporting documentation when billing with Modifier 76

Providers must submit supporting documentation with the claim when billing with Modifier 76; claims submitted without supporting documentation will be denied and providers will be asked to submit the required documentation for reconsideration of reimbursement.

If a claim is submitted with Modifier 76 without supporting documentation, the claim will be denied.
Providers will be asked to submit the required documentation for reconsideration of reimbursement.

Denial Risk

Professional services subject to clinical review

Professional services (other than radiology) appended with Modifier 76 are subject to clinical review and reimbursement will be determined after that review.

Definitions: Duplicate and Subsequent Services

Duplicate or Subsequent Services on the Same Date of Service

Primary duplicate-service modifierModifier 91 is used to indicate duplicate or subsequent services on the same date of service

Other modifiers referencedModifiers 50 and 51 (multiple and bilateral surgery) and Modifiers 80, 81, 82, AS (assistant at surgery) are listed as related duplicate/subsequent usages

Not allowed with Modifier 76Evaluation and management (E/M) codes, laboratory codes, preoperative or postoperative components, and any procedure repeated more than once are non-reimbursable when paired with Modifier 76

Coding noteStandard correct coding applies and contract, state, federal, or CMS requirements may supersede