CurrentAnthemPolicy G-06019

Reimbursement Policy Modifier 77

Governance of Anthem New York Medicaid reimbursement when modifier 77 is reported to indicate a procedure or service was repeated by another physician; affects professional and facility claims and providers billing Medicaid in NY.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Modifier 77

Policy CodePolicy G-06019

Change TypeNo material changes

Effective DateOct 3, 2018

Next Review Date

Key ActionProviders must submit supporting documentation with claims that report modifier 77 or the claim will not be eligible for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%reimbursement rate for nonsurgical repeated procedures

100%reimbursement rate for surgical repeated procedure (component)

2maximum repeated surgical procedures

NYjurisdiction

When Modifier 77 Is Reimbursable

Modifier 77 coverage criteria

Reimbursement is allowed under specified conditions and excluded in listed situations.

ALL of the following

Provider type / claim type
- Professional claims: repeat is subsequent to the original procedure or service.
- Facility claims: repeat is on the same date as the original procedure or service.
Payment level for nonsurgical repeated procedures: 100% of the applicable fee schedule or contracted/negotiated rate.
Payment level for surgical repeated procedures: 100% of the applicable fee schedule or contracted/negotiated rate for the surgical component only; limited to a total of two surgical procedures.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Modifier 77

Policy CodePolicy G-06019

Change TypeNo material changes

Effective DateOct 3, 2018

Next Review Date

Key ActionProviders must submit supporting documentation with claims that report modifier 77 or the claim will not be eligible 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.

If a repeated surgical procedure involves an assistant surgeon or multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply.

Providers must submit supporting documentation with the claim to support use of modifier 77; claims submitted without supporting documentation are not eligible for reimbursement and providers will be asked to submit documentation for reconsideration.

Exclusions

Not reimbursable when modifier 77 is appended to an inappropriate procedure code.
Not reimbursable for any procedure repeated more than once.
Not reimbursable for the preoperative or postoperative components of a surgical procedure.
Not reimbursable when appended to evaluation and management (E/M) codes.

Coding and Repeat Limits

Modifier guidanceModifierCovered

Modifier 77

Added to repeated procedure/service performed by another physician; should not be appended to an E/M service.

Repeat limits and exclusions

Repeat limitNot reimbursable for any procedure repeated more than once.

Pre/postoperative exclusionNot reimbursable for the preoperative or postoperative components of a surgical procedure.

Inappropriate code exclusionNot reimbursable when modifier 77 is appended to an inappropriate procedure code.

E/M services exclusionNot reimbursable when appended to evaluation and management (E/M) codes.

Documentation, Review, and Authorization Requirements

Documentation Required

Submit supporting documentation with claims using modifier 77

Providers must submit supporting documentation for the use of modifier 77 with the claim; 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 of reimbursement.

Failure to use modifier 77 when appropriate may result in the procedure or service not being approved.

Prior Authorization

Clinical review and authorization required for professional services

Professional services (other than radiology) are subject to clinical review for consideration of reimbursement and must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.
If coding/billing or reimbursement policies are not followed, the claim may be rejected, denied, or subject to recovery/adjustment.

Terms and Coding Notes

Modifier 77 definition

DefinitionModifier 77 indicates that a basic procedure or service was repeated by another physician or other qualified healthcare professional subsequent to the original procedure or service.

Reporting noteReport the circumstance by adding modifier 77 to the repeated procedure or service.

E/M guidanceThis modifier should not be appended to an E/M service.

Related coding note

Coding principleStandard correct coding applies.

ApplicabilityApply usual coding guidelines when determining whether modifier 77 is appropriate for a repeated service.

Claim submissionEnsure the correct procedure code and modifier usage per coding standards to avoid denial.