CurrentAnthemPolicy G-06019

Modifier 77 reimbursement

Defines Anthem's reimbursement rules for services billed with Modifier 77 (repeat procedure by another physician), including when reimbursement is allowed, required documentation, and excluded uses; applies to providers submitting claims to Anthem Blue Cross.

Policy Summary

PayerAnthem

PolicyModifier 77 reimbursement

Policy CodePolicy G-06019

Change TypeAdministrative and bibliographic updates

Effective Date08/07/2020

Next Review Date

Key ActionSubmit supporting documentation with the claim to justify use of Modifier 77; claims without documentation will be denied.

SourceLink

POLICY UPDATE CHANGES

Updated policy template; removed 'Repeat Procedure by Another Physician or other Qualified Health Care Professional' from the policy title; removed 'subsequent' definition.

Updated References and Research Materials and Related Policies and Materials sections.

100%nonsurgical reimbursement

100%surgical component reimbursement

2max repeated surgical procedures

Requiredsupporting documentation

Not reimbursableuses not reimbursable

Modifier 77 Coverage Criteria

Modifier 77 coverage criteria

Anthem allows reimbursement for procedures billed with Modifier 77 under these conditions and excludes reimbursement in the listed scenarios.

ALL of the following

Claim type timing
- Subsequent to the original procedure or service for professional claims.
- On the same date as the original procedure or service for facility claims.

Reimbursement levels

For a nonsurgical procedure or service: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate.

Policy Summary

PayerAnthem

PolicyModifier 77 reimbursement

Policy CodePolicy G-06019

Change TypeAdministrative and bibliographic updates

Effective Date08/07/2020

Next Review Date

Key ActionSubmit supporting documentation with the claim to justify use of Modifier 77; claims without documentation will be denied.

SourceLink

On This Page

Coding and Reimbursement Limits

ModifierModifierCovered

Modifier 77

Repeat procedure by another physician

Maximum reimbursable repeated surgical procedures

Maximum reimbursable repeated surgical procedures (surgical component)Limited to a total of two surgical procedures

Reimbursement rate for surgical component100% of applicable fee schedule or contracted/negotiated rate

Applies to surgical component onlyAssistant surgeon and multiple procedure rules and fee reductions may apply when performed with an assistant or multiple surgeries

Documentation and When to Use Modifier 77

Documentation Required

Documentation required for reimbursement

Providers must submit supporting documentation when billing Modifier 77. Required documentation should clearly show that the procedure or service was repeated by a different physician and include dates, times, operative or procedure reports, and any relevant clinical rationale. If a claim is submitted with Modifier 77 without supporting documentation, the claim will be denied. Providers will be asked to submit the required documentation for reconsideration of reimbursement. Failure to use Modifier 77 when appropriate may also result in denial of the procedure or service.

Required: operative/procedure reports, dates and times, identity of the repeating physician, clinical rationale for repeat service
Denial risk if documentation not provided: claim denial and request for documentation for reconsideration

Billing Rule

When Modifier 77 applies

Modifier 77 indicates a procedure or service was repeated by another physician. Apply Modifier 77 as follows unless provider, state, federal, or CMS contracts or requirements indicate otherwise: - For professional claims: use Modifier 77 for a repeat procedure subsequent to the original procedure or service. Reimbursement for nonsurgical procedures/services will be 100% of the applicable fee schedule or contracted/negotiated rate. For surgical procedures, reimbursement is 100% of the surgical component only and is limited to a total of two surgical procedures. Professional services (other than radiology) are subject to clinical review. - For facility claims: use Modifier 77 when the repeat procedure is performed on the same date as the original procedure or service. The same reimbursement rules above apply. Additional billing notes: if a repeated surgical procedure involves an assistant surgeon or is performed with multiple surgeries, applicable assistant surgeon and multiple procedure rules and fee reductions apply.

Applies when repeated by another physician
Professional claims: subsequent to original procedure or service
Facility claims: on the same date as the original procedure or service
Reimbursement: nonsurgical = 100% fee schedule; surgical = 100% of surgical component, limited to two procedures
Professional services (except radiology) may require clinical review

OpenPayer

Modifier 77 reimbursement

Modifier 77 Coverage Criteria

Coding and Reimbursement Limits

Documentation and When to Use Modifier 77

Key Definitions