General Surgery Coding Alert

Can you tell when a different modifier is a better choice? Here's how

Medicare considers modifiers 76 and 77 -informational only- -- meaning that they will not affect your reimbursement -- but encourages practices to use these modifiers -when appropriate.- Make sure you know what that means, because it can affect your pay-up.

Don't make this mistake: You may think, -If 76 and 77 have no effect on reimbursement, why bother?-

Here's your reason: Not only do correct coding guidelines direct you always to report your claims to the highest level of precision, but knowing how to apply 76 and 77 properly will also help you to know when to use other, payable modifiers.

Day and Procedure Must Be Identical

You should append modifiers 76 (Repeat procedure by same physician) and 77 (Repeat procedure by another physician) when the same physician or a different physician, respectively, must repeat an identical procedure for the same patient on the same day.

Example: A patient with an aortofemoral bypass graft presents with reduced circulation to his leg. A CT scan indicates that the graft has thrombosed (996.74). The surgeon performs thrombectomy (35875, Thrombectomy of arterial or venous graft [other than hemodialysis graft or fistula]) with good result and admits the patient for observation.

Four hours later, the patient again exhibits signs of reduced circulation.‧A follow-up CT indicates that another clot has formed at the same location. The surgeon again performs thrombectomy and follows with more aggressive anticoagulation.

In this case, you should report 35875-76 for the repeat thrombectomy by the same physician.

Billing tip: When medical necessity supports repeating a procedure more than twice, you should report the second line with modifier 76 or 77 (as appropriate) and the appropriate number of units in the units field. For instance, for three thrombectomies by the same physician on the same day (which would be very rare), you would report 35875, 35875-76 x 2.

Rule of thumb: If the physician repeats a service more than once (that is, if he provides the service three or more times for the same patient on the same day), you should provide additional documentation in the claim's narrative field to support the medical necessity of the repeat services. The physician's notes should clearly indicate why these repeat procedures were needed.

Important: You should be sure to file both claims on the same CMS-1500 claim form. If you separate the claims for the two identical, same-day services, Medicare will deny the second claim as a duplicate service, even if you append modifier 76 (or 77).

Avoid Confusion With Other Modifiers

Remember, modifiers 76 and 77 only apply if the repeat procedure occurs on the same day as the original procedure, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC. In addition, the repeat procedure should be identical to the initial procedure (and take place, for example, in the same anatomic area), or modifiers 76 and 77 are not appropriate.

Example 1: The patient undergoes esophagogastroduodenoscopy (EGD) with control of gastrointestinal bleeding in the morning (43255, Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method). Later that same day, the patient develops bleeding again, which requires the surgeon to repeat the earlier procedure.

In this case, you should append modifier 76 to 43255 to describe the repeat procedure on the same day as the initial procedure.

-What if- scenario: If the second endoscopy occurred several days after the initial endoscopy (but still within the global period), modifier 76 no longer applies. Instead, you would append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 43255.

If the physician repeats a procedure at different sites, you should not report 76 or 77. In most cases, you will instead use modifier 59 (Distinct procedural service) to differentiate the various sites.

Example 2: The surgeon removes three lesions, all from the left arm, all benign and measuring 2.5 cm each.

In this case, you should report 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 2.1 to 3.0 cm) with 216.6 (Benign neoplasm of skin; skin of upper limb, including shoulder) and 11403-59 x 2 with 216.6.

Because the lesion removals occurred at different sites (although within the same general anatomic area), modifier 59, rather than 76, is appropriate, Cobuzzi says.