CurrentAnthemPolicy G-06018

Reimbursement Policy Modifier 76

Defines Anthem Blue Cross Medicare Advantage reimbursement rules for using modifier 76 to indicate a repeated procedure by the same physician, and the documentation and billing conditions required for reimbursement. Applies to providers submitting claims under this payer.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Modifier 76

Policy CodePolicy G-06018

Change TypeNo material change

Effective DateJan 26, 2026

Next Review Date

Key ActionSubmit supporting documentation with the claim to justify use of modifier 76; claims without documentation are ineligible for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%reimbursement for nonsurgical repeated procedures or surgical component when allowed

limited to twomaximum total repeated surgical procedures reimbursed

not reimbursedmodifier 76 used for preoperative or postoperative surgical components

documentation requiredsupporting documentation must be submitted or claim ineligible

not for E/Mmodifier 76 should not be appended to E/M services

When Modifier 76 Is Reimbursed

Modifier 76 reimbursement criteria

Covered when ALL of the following conditions are met:

Modifier 76 indicates the procedure or service was repeated by the same physician (subsequent to the original for professional claims; on the same date as the original for facility claims).

For nonsurgical procedures or services: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate.

For surgical procedures: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate for the surgical component only.

Reimbursement for repeated surgical procedures using modifier 76 is limited to a total of two surgical procedures.

Provider must submit supporting documentation with the claim to justify use of modifier 76; if documentation is not submitted the claim will be ineligible for reimbursement and the provider will be asked to submit documentation for reconsideration.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Modifier 76

Policy CodePolicy G-06018

Change TypeNo material change

Effective DateJan 26, 2026

Next Review Date

Key ActionSubmit supporting documentation with the claim to justify use of modifier 76; claims without documentation are ineligible for reimbursement.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

When a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and multiple procedure rules and fee reductions apply.

Nonreimbursable uses (any of the following) - do NOT reimburse

Modifier 76 appended to an inappropriate procedure code.
Any procedure repeated more than once.
Modifier 76 used for the preoperative or postoperative components of a surgical procedure.

Modifier 76 should not be appended to evaluation and management (E/M) services.

Modifier and Procedure Coding Guidance

Modifier 76 usagemixed

No codes listed

Repeated surgical procedures limit

Reimbursement limitFor a surgical procedure: reimbursement is limited to 100% of the surgical component only, and limited to a total of two surgical procedures when modifier 76 is applied.

Nonsurgical proceduresFor a nonsurgical procedure or service: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate when modifier 76 is appended.

Nonreimbursable usesModifier 76 is not allowed for any procedure repeated more than once or for preoperative/postoperative components of a surgical procedure.

Assistant/multiple surgery interactionIf a repeated surgical procedure is performed with an assistant surgeon or with multiple surgeries, assistant surgeon and multiple procedure rules and fee reductions apply.

Documentation and Billing Requirements

Documentation Required

Submit supporting documentation with the claim for modifier 76

Providers must submit supporting documentation with the claim to justify use of modifier 76; if supporting documentation is not submitted the claim will not be eligible for reimbursement and the provider will be asked to supply the documentation for reconsideration.

If documentation is missing the claim is ineligible for reimbursement.
Providers will be asked to submit the required documentation for reconsideration of reimbursement.

Key Terms

Modifier 76 — definition

DefinitionModifier 76 indicates a procedure or service was repeated by the same physician or other qualified healthcare professional subsequent to the original procedure or service.

ReportingThis circumstance may be reported by adding modifier 76 to the repeated procedure or service; providers must submit supporting documentation with the claim to justify its use.

E/M servicesModifier 76 should not be appended to an E/M service.