Wiki Sequencing and appropriate modifiers

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ktb_thomas

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I know modifiers, modifier sequencing and how to find modifiers that are acceptable for a given CPT Code, but we're getting frequent denials: 4-PX INCONS W/ MODIF/REQD MODIF MISSNG We've recently been informed that modifier 78 and 76 can not be used on same line item Is there a resource to determine what modifiers can not be used together and how do you find what modifier Insurance Company is seeking when they denial with the above mentioned denial reason? The Insurance Reps just say they can't tell me how to code.
 
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I would recommend against using modifier 76 on a surgical procedure. Although the CPT code may be the same, it is not a repeat procedure, it is a different procedure on a different site that happens to be coded with the same CPT. 76 modifier is commonly used for diagnostic tests that have to be repeated on the same day, usually due to a change in patient condition, for example EKGs or chest x-rays. I think that is likely the cause of the denial in this situation. For surgical procedures I use 59 or XS to indicate that the second procedure was distinct from the first, and have almost never run into a problem with that.

I agree with trarut's post too - most large payers do publish modifier policies on their web sites which described their own internal expectations for the use of modifiers and this can be very helpful for specific guidance on modifier denials.
 
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Optum publishes a book called "Understanding Modifiers" that I found useful over the years for general guidance. For payer specific denials, I would check their coverage and reimbursement policies for modifier guidance.

The modifiers in your question are telling a conflicting story, which may be the cause of the problem you're having. Using -76 tells the payer that the provider is repeating a procedure s/he already performed. The -78 says the provider is doing a new procedure, unplanned yet related to the original procedure (not a repeat procedure). Which scenario explains the procedure you are billing for?
 
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