CurrentBlue Cross Blue Shield - NevadaPolicy G-06032

Duplicate or Subsequent Services on the Same Date of Service

This reimbursement policy governs when Anthem Medicare Advantage will reimburse duplicate or subsequent services provided to the same member on the same date of service and the modifier usage required; it applies to participating providers and facilities subject to provider, state, federal, or CMS contract requirements.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyDuplicate or Subsequent Services on the Same Date of Service

Policy CodePolicy G-06032

Change TypeClarified (operational relocation of modifiers)

Effective DateApr 11, 2022

Next Review Date

Key ActionClaims for duplicate or subsequent services must be billed with appropriate modifiers; claims will be reviewed and may be denied if submitted without proper modifier usage.

SourceLink

POLICY UPDATE CHANGES

Moved modifiers to Related Coding section and made minor language changes.

1policy updated on biennial review (04/11/2022)

Medicare Advantagelines of business

Modifiers requiredfor reimbursement of duplicate/subsequent services

Duplicate or Subsequent Service Coverage Rules

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Duplicate/Subsequent Service Coverage Rules

Reimbursement stance and rules for duplicate or subsequent services on the same date of service.

Anthem Medicare Advantage 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 or requirements indicate otherwise.

Reimbursement of duplicate or subsequent services is contingent on correct usage of the modifiers specified in the Related Coding section; these modifiers indicate the service was appropriately repeated or additionally billed for the same member.

Claims billed with suspected duplicate or subsequent services will be reviewed; claims will be denied when determined to be duplicate or subsequent without appropriate modifier documentation.

When an individual service is considered bundled with a more comprehensive service and billed on the same claim line, the claim line for the individual service will be denied through code editing; if billed on separate claims the claim will be reviewed and applicable modifiers that indicate distinctness should be used.

Refer to specific modifier policies for state applicability.

Coding and Detection Rules

Reimbursement Modifiersmixed

No codes listed

Duplicate service detection criteria — when a service is suspected duplicate

Match on member, procedure code, and date of serviceA service is suspected duplicate if the following elements on the claim match: Member, Procedure code, Date of service.

Match on member, date, charge amount, provider, rendering providerDuplicate services are also flagged when the following claim elements match: Member, Date of service, Charge amount, Provider of service, Rendering provider.

Subsequent service definitionA subsequent service is a medically necessary service performed for the same member more than once on the same date of service.

Use for detection and reviewThese matching-element criteria are used to identify claims for review as potential duplicate or subsequent services.

Billing Modifiers and Claim Review

Prior Authorization

Bill duplicate/subsequent services with appropriate modifier; claims will be reviewed and may be denied

Claims for duplicate or subsequent services must be billed with an appropriate modifier indicating the service was appropriately repeated or additionally billed for the same member. Anthem Medicare Advantage will review claims billed with suspected duplicate or subsequent services and will deny services determined to be duplicate or subsequent when billed without the appropriate modifier; when an individual service is bundled and billed on the same claim line it will be denied through code editing, and if billed on separate claims the claim will be reviewed.

Use the modifiers located in the Related Coding section to indicate distinctness or that the service was repeated.
Bundled individual services billed on the same claim line will be denied through code editing; separate-claim situations will be reviewed for modifier applicability.
Refer to specific modifier policies for state applicability and any provider, state, federal, or CMS contract requirements that may override this policy.

Definitions: Duplicate and Subsequent Services

Duplicate Services / Subsequent Service — definition and examples

Duplicate Services — core flagged matchesDuplicate Services are flagged when claim elements match: Member; Date of service; Charge amount; Provider of service; Rendering provider.

Suspected duplicate — procedural matchA service is suspected duplicate when Member, Procedure code, and Date of service match on the claim.

Subsequent Service — same-day repeatSubsequent service: a medically necessary service performed for the same member more than once on the same date of service.

ApplicationThese definitions are applied to identify and review claims that may be duplicate or subsequent services for potential denial or modifier requirement.