Revenue Cycle Insider

Question: A patient had an electrocardiogram (ECG) at 8 a.m. for chest pain, which was interpreted by the patient’s usual cardiologist. Later that afternoon, just before the practice closed, the patient called and reported a feeling chest pain of a different sensation, and a different cardiologist in the practice group was consulted; they then ordered and interpreted an additional ECG. Our payer denied the second service as a duplicate. How should we report this repeated service?

South Carolina Subscriber

Answer: A repeat-procedure modifier may be needed to distinguish the medically necessary repeat service from an apparent duplicate, depending on payer requirements. The deciding factor for selecting a modifier is who performed the additional, repeated procedure on the same date of service (DOS).

If the same provider performs a repeat service, look to modifier 76 (Repeat procedure or service by same physician or other qualified health care professional). If a different provider performs the same service, look to modifier 77 (Repeat procedure by another physician or other qualified health care professional). Before choosing between these modifiers, check the payer’s rules for physicians of the same specialty within the same group practice, because payer claims-processing rules may treat those physicians as the same physician for this purpose.

If you submit a claim with what appears to be duplicate services on the same DOS without a modifier to provide context and documentation to support that the repetition was deliberate and medically necessary, the payer may see the same code being billed multiple times as exact duplicates and deny the successive services.

Note: If the service was repeated due to a technical issue, like a problem with the equipment, neither of these modifiers is appropriate. Additionally, you wouldn’t append modifiers 76 or 77 to codes for evaluation and management (E/M) or laboratory services.

So, in this scenario, for the first ECG, you’d report 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). As another cardiologist performed and interpreted the second, medically necessary ECG later that same day, appending modifier 77 would be appropriate, meaning you’d report 93000-77. However, you should verify the respective payer’s repeat-procedure policy and documentation requirements before submitting the claim, particularly when both physicians belong to the same group practice.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC