CurrentHighmark Blue Cross Blue Shield WnyPolicy G-06018

Reimbursement Policy Modifier 76

Defines Highmark BCBS WNY reimbursement rules for claims billed with modifier 76 (repeat procedure by same physician) for MMC, HARP, CHPlus, and Essential Plan members. Applies to professional and facility claims as specified.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyReimbursement Policy Modifier 76

Policy CodePolicy G-06018

Change TypeTemplate and definitions updates

Effective Date01/26/2026

Next Review Date

Key ActionSubmit supporting documentation with claims billed with modifier 76; claims missing documentation are not eligible for reimbursement.

SourceLink

POLICY UPDATE CHANGES

Updated Definitions section by adding modifier 76.

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

100%reimbursement for nonsurgical repeated procedures

100%reimbursement for surgical component (limited)

2max repeated surgical procedures

01/26/2026last approval date

Modifier 76 — Coverage Criteria

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyReimbursement Policy Modifier 76

Policy CodePolicy G-06018

Change TypeTemplate and definitions updates

Effective Date01/26/2026

Next Review Date

Key ActionSubmit supporting documentation with claims billed with modifier 76; claims missing documentation are not 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.

Modifier 76 coverage criteria

Covered when ALL of the following conditions are met:

ALL of the following

Setting-specific timing
- For professional provider claims: the repeated procedure/service is subsequent to the original procedure or service.
- For facility claims: the repeated procedure/service is on the same date as the original procedure or service.
Supporting documentation for the use of modifier 76 is submitted with the claim.
Services meet applicable authorization and medical necessity guidelines; professional services (other than radiology) may be subject to clinical review.

ALL of the following

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, limited to a total of 2 surgical procedures.

ALL of the following

If a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply.
If modifier 76 is submitted without supporting documentation the claim will not be eligible for reimbursement; providers will be asked to submit documentation for reconsideration.

Relevant Codes and Limits

ModifierModifierCovered

76	Modifier 76: Procedure or service repeated by same physician; should not be appended to an E/M service

Maximum reimbursable repeated surgical procedures

Maximum reimbursable repeated surgical proceduresTwo total repeated surgical procedures are reimbursable for the surgical component only (100% of fee schedule/contracted rate).

Surgical component reimbursement rate100% of the applicable fee schedule or contracted/negotiated rate for the surgical component.

Scope of limitLimit applies to repeated surgical procedures; nonsurgical procedures are not subject to the two-procedure surgical limit.

Documentation & Claim Submission Requirements

Documentation Required

Submit supporting documentation with claims billed using modifier 76

Providers must submit supporting documentation for the use of modifier 76 with the claim; claims submitted with modifier 76 without supporting documentation will not be eligible for reimbursement and providers will be asked to submit the required documentation for reconsideration. Professional services (other than radiology) may be subject to clinical review, and failure to use modifier 76 when appropriate may result in the procedure or service not being approved.

Submit supporting documentation at time of claim submission when billing with modifier 76.
If documentation is not submitted, the claim is ineligible for reimbursement and must be resubmitted with required documentation for reconsideration.
Professional (non-radiology) services billed with modifier 76 may undergo clinical review for reimbursement determination.

Key Definitions

Modifier 76

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

Usage noteThis circumstance may be reported by adding modifier 76 to the repeated procedure or service; it should not be appended to an E/M service.

Documentation requirementProviders must submit supporting documentation with the claim when modifier 76 is used; claims without documentation are not eligible for reimbursement.

Clinical reviewProfessional services (other than radiology) with modifier 76 may be subject to clinical review for reimbursement consideration.

Related Coding

Correct coding principleStandard correct coding applies.

CompatibilityModifier 76 should not be appended to E/M services per definition guidance.

Billing impactIf modifier 76 is submitted without supporting documentation the claim will not be eligible for reimbursement and providers will be asked to submit documentation for reconsideration.