Modifier 77 repeat procedure reimbursement
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Defines reimbursement rules for procedure codes appended with modifier 77 for Highmark BCBS WNY Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan members; explains required documentation and limits for professional and facility claims.
No material clinical or coverage changes in this revision.
Modifier 77 Coverage Criteria
Modifier 77 coverage criteria
Reimbursement rules when modifier 77 is appended to a claim:
ALL of the following
Professional or Facility context
- Professional claims: modifier 77 indicates the procedure was repeated by another physician subsequent to the original procedure or service.
- Facility claims: modifier 77 indicates the procedure was repeated on the same date as the original procedure or service.
ALL of the following
- For a nonsurgical procedure or service: 100% of the applicable fee schedule or contracted/negotiated rate.
- For a surgical procedure: 100% of the applicable fee schedule or contracted/negotiated rate for the surgical component only; reimbursement for repeated surgical procedures is limited to a total of two procedures.
ALL of the following
- Professional services (other than radiology) are subject to clinical review for consideration of reimbursement.
- Providers must submit supporting documentation with the claim when modifier 77 is used; a claim submitted with modifier 77 without supporting documentation will not be eligible for reimbursement and providers will be asked to submit documentation for reconsideration.
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.
Nonreimbursable uses (modifier 77 not allowed)
- With an inappropriate procedure code.
- For any procedure repeated more than once (reimbursement limited to a total of two repeated surgical procedures).
- For the preoperative or postoperative components of a surgical procedure.
- When appended to evaluation and management (E/M) codes.
Coding Guidance and Limits
| modifier 77 | Indicates a basic procedure or service was repeated by another physician or qualified healthcare professional; should not be appended to E/M services. |
Documentation & Claim Submission Requirements
Submit supporting documentation when using modifier 77
Providers must submit supporting documentation for the use of modifier 77 with the claim; a claim submitted with modifier 77 without supporting documentation will not be eligible for reimbursement and providers will be asked to submit the required documentation for reconsideration.
- Documentation must accompany the claim to support clinical review for professional services (other than radiology).
- If documentation is not included, the claim will be ineligible for reimbursement and may be requested for reconsideration.
Term: Modifier 77
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