Wiki using Modifier 76 and 59 on same DOS

[laurenshirazi]

Hello!
I am getting feedback from Providence that conflicts with what I understand to be the use of modifier 76 and 59. Here's how we had bill and WERE PAID ON in the past. 95117(59), 96372, 96372(76), 96372(76). Since Providence did a "clinical edit update" as of 6/1/17, they are now REJECTING this combination and advising I submit: 95117, 96372, 96372(59), 96372(59). This seems to contradict the use of the modifiers and I was looking for professional advise (as I am a CPC-A).

CPT Codes 95115 and 95117 - One (1) unit only, when billing for one or more injections given on the same day. ... Code 95115 may be used for a single injection; 95117 covers two or more injections. The correct quantity (number of units) is always one (1) for both codes.
CPT® 96372 Therapueutic, prophylactic, or diagnostic injection, specify substance, or drug; subcutaneous or intramuscular

Thank you so much! -Lauren

 

[OncologyOKC]

Hi Lauren,

When it comes to 96372 billing the thing to remember is that each drug/injection is a distinct or independent service(s) performed on the same day, so the modifer 59 comes into play. The 76 modifier is used for a Repeat procedure, for instance a chest xray performed in the AM and then having to perform it again in the PM. That is considered a repeat procedure. Hope this helps.

 

[yinna82]

I see this all the time and the 76 will be denied upon manual review as its not a repeat within the global period, it's a separately and distinct procedure within the same encounter. OncologyOKC's explanation is very on point.

 

[ellzeycoding]

The problem is that some carriers (like Noridian) do not permit 59 on identical codes. They say it's ONLY to be use on edit pairs listed in the National Correct Coding Initiative. I realize that this is a different carrier (and not Noridian), but the carriers are inconsistent. Some won't accept 59 on identical procedures and want 76 in this case. Some won't accept 76 on surgical procedures at all. Some do.