Reimbursement Policy Modifier 76
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Defines Highmark BCBS WNY reimbursement rules for procedure or service repeats using modifier 76 for MMC, HARP, CHPlus, and Essential Plan members; affects professional and facility claims and providers billing these lines of business.
Updated Definitions section by adding modifier 76.
Modifier 76 Coverage and Reimbursement Criteria
Modifier 76 reimbursement criteria
Reimbursement and exclusions when modifier 76 is appropriately used:
ALL of the following
- For a nonsurgical procedure or service: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate.
- For a surgical procedure: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate for the surgical component only; limited to a total of two surgical procedures.maximum reimbursable repeated surgical procedures = 2
ALL of the following
- Professional services (other than radiology) with modifier 76 are subject to clinical review for consideration of reimbursement.
Supporting documentation must be submitted with the claim; claims submitted without supporting documentation will not be eligible for reimbursement and providers will be asked to submit documentation for reconsideration.
- Failure to use modifier 76 when appropriate may result in the procedure or service not being approved.
Nonreimbursable situations
- Modifier 76 appended to an inappropriate procedure code.
- Any procedure repeated more than once (not reimbursable).
- Modifier 76 appended to the preoperative or postoperative components of a surgical procedure (not reimbursable).
Coding Guidance and Repeat Limits
| Modifier 76 | Indicates procedure/service was repeated by the same physician; should not be appended to an E/M service. |
Documentation, Authorization, and Billing Actions Required
Submit supporting documentation when appending 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; providers will be asked to submit the required documentation for reconsideration of reimbursement.
- Supporting documentation must accompany the claim at time of submission for professional services (other than radiology) subject to clinical review.
- If documentation is not provided, the claim will be ineligible for reimbursement and may be reconsidered only after submission of the required records.
Ensure authorization and medical necessity for billed services
Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and the member's state of residence; failure to meet these requirements may result in claim denial or recovery actions.
- Ensure services have any required prior authorization and are clinically supported in the medical record.
- Use proper CPT/HCPCS/revenue codes and maintain documentation in medical record or office notes to support billed services.
Key Definitions
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