Occasionally, a procedure may need to be repeated. Reporting the repeated service may be confusing, especially if performance of the repeated procedure takes place during the global period of the original case. This is a situation that calls for use of a modifier appended to the repeated service.
The modifier 76 is used to indicate a “repeat procedure or service by same physician or other qualified health care professional.” It identifies that the exact same service was repeated by the same provider. According to the American Medical Association’s CPT Changes 2008: An Insider’s View, use of modifier 76 is not restricted to procedures performed on the same day. The repeated service could be surgical or diagnostic, but cannot be an evaluation and management (E&M) service. This nuance was clarified in the CPT Changes 2011: An Insider’s View. The most important thing to remember is that both services—the original and the repeat—must be described by the exact same CPT code.
Closed fracture treatment
Let’s look at the following case of closed treatment of a radius fracture as an example.
An orthopaedic surgeon is called to the emergency department to evaluate a patient with a fractured radius. The orthopaedic surgeon determines that the fracture requires manipulation, which he performs. Following the manipulation, the surgeon orders and evaluates radiographs, which show that the fracture is well aligned. He applies a splint and instructs the patient to follow up with him in one week for casting.
Focusing only on the fracture care, this service is reported using code 25505—closed treatment of radial shaft fracture; with manipulation. The patient returns the following week, but radiographs reveal the reduction has been lost. The surgeon repeats the treatment and reports the service using code 25505-76.
Appending modifier 76 to the second procedure results in a reduction in reimbursement of about 30 percent for the subsequent procedure, but links the 90-day global period to the original surgery. This means that 90 days after the original reduction, the global period would be over and the services rendered to the patient could be reported for reimbursement with appropriate CPT codes. This is similar to the reimbursement policy associated with modifier 78 when it is used to indicate a patient has been returned to the operating room for treatment of a complication.
If the fracture required a different treatment, such as an open reduction, modifier 76 should not be appended to the subsequent procedure because the open reduction is not a repeat of the previous closed treatment.
Planned repeats and staged procedures
Modifier 76 should not be used to report the repeat of a planned or anticipated procedure, such as débridements associated with an open fracture. Even if the exact same débridement service is done in the global period, it would be reported by appending a modifier 58 to the subsequent débridement because the service was planned or anticipated at the time of the original operation. When modifier 58 is used to describe staged or related procedures or services by the same physician during the postoperative period, no reduction in reimbursement is taken and the global period resets, beginning anew on the date of the second operation.
Modifier 76 may also be used to report the repeat of a radiographic evaluation, such as a postreduction film taken in the office. This tells the payer that the charge and radiographs are not duplicates, but that the same view(s) was taken and read twice. Currently, radiographs should not be subject to the discount.
Same day service?
Some payers and Medicare carriers may interpret modifier 76 differently and restrict its use to services performed on the same day, even though this is clearly not part of the CPT definition. Payers that restrict the use of modifier 76 to the same day or same 24-hour period often use the multiple procedure reduction of 50 percent for the subsequent procedure. They also state that the modifier should not be used to report a failure or inadequate outcome of the original procedure.
Appending modifier 76 during the global period is important because it prevents the payer from assuming that the identical service is being reported a second time in error.
Knowing the reimbursement policy for modifier 76 and other CPT modifiers used by your top payers is important to your bottom line.
Margaret M. Maley, BSN, MS, is a consultant with KarenZupko & Associates.