Modifier 76

Modifier 76 Description, Uses, Guidelines & Examples (2022)

Modifier 76 is applied for service when a similar service performs by the Same Physician or healthcare provider on the same day.

Modifier 76 Description

Modifier 76 is applied for service when a similar service performs by the Same Physician or healthcare provider on the same day. If multiple or identical services perform in one day, they bundle together. CMS allows limited amounts of the unit to bill on one date. Modifier requires to unbundled the services.

Modifier 76 usually reports for radiology services, which are rendered frequently in one day. Surgical procedures can occur twice on the same day. For Instance, EKG performs by one physician, and the results were questionable preliminary findings. 

The second interpretation or opinion requires the same physician to get a consistent result. In contrast, any surgical procedure repeats due to unavoidable circumstances, and it is appropriate to report with modifier 76 to unbundle the services. 

Evaluation and management (E/M) codes do not accept modifier 76 and are medically not appropriate. Only one E/M service can perform on the same date for one reason. Another physician can report the other service if the patient encounters another reason on the same day with modifier 25 instead of modifier 76.

Medical documentation must support the medical necessity of the repeated service. The insurance or third party may deny it and check the appropriate guidelines for the repeated services. 

76 modifier

What Is Modifier 76?

Modifier 76 is applied for service when a similar service performs by the Same Physician or healthcare provider on the same day. If multiple or identical services perform in one day, they bundle together. CMS allows limited amounts of the unit to bill on one date. Modifier requires to unbundled the services.

When To Use Modifier 76

Modifier 76 applies to service when performed on the same day.

Modifier 76 applies to services performed on the same day by the same physician.

Modifier 76 is applicable for injection, surgical procedures, X-rays, etc. 

Modifier 76 Guidelines

Documentation supports the medical necessity of service if repeated by the same physician on the same day. The patient condition reflects the significance of the service. 

The patient visited the physician for shoulder pain in the morning and got a steroid injection for the pain—similarly, another encounter with the same physician for diabetes. E/M codes do not accept modifier 76, which is inappropriate to report. Modifiers 24 and 25 apply when the E/M service repeats if significantly identifiable service. 

The service seems unnecessary to the physician. For instance, the patient wants to repeat the same physician’s service for a second interpretation. If Medicare denies this service, the beneficiary will be responsible for payment. 

Modifier 76 attach to unbundle the service, and modifier GA indicates that Medicare denies paying for this service. Patients are responsible for paying for the services furnished by the physician.

Modifier 76 does not apply to specific services, and it is only applicable when services perform twice.

Modifier 76 does not include different services rendered by the physician. It is only appropriate when services duplicate. For example, a Doppler ultrasound of the abdomen and an Ultrasound of the abdomen perform on the same date. Modifier 59 appropriates for these services as these services are distinct and not identical. Therefore, adding modifier 76 to unbundle these services does not become relevant.

Radiologic and surgical procedures accept modifier 76. For example, a patient had surgical removal of a foreign body in the right eye by physician A in the morning. Physician A left the office. The patient still feels irritation in the right eye and presents similarly to the office. The same physician performed surgical procedures again to remove retained contents. Modifier 76 is appropriate to bill with Physician A’s surgical procedure.

Claim reports with the separate line when modifier 76 is attached. Two units of procedure shall deny by the insurance, like 71046×2. It appropriates to reports such as:

  • 71046-R07.9 Physician A
  • 71046-76-R07.9 Physician A

If modifier 26 bills with radiology procedure, modifier 76 orders second in the line such as 71046-26-76.

Modifier 76 does not appropriate bundled and multiple services on the same day. It is suitable to report with modifiers 59 and 51. For example, service separately bills when imaging guidance does not include in the procedure code. They may bill with modifier 59 if any crosswalk is present. Modifier 51 bills for multiple services such as two similar procedures performs on the 1st digit and 2nd digit. Another service appropriates to report with modifier 51.

Modifier 76 and 77

Modifier 76 is applied for service when a similar service performs by the Same Physician or healthcare provider on the same day. For example, Physician A performed the procedure in the afternoon, and the same physician repeated the service in the evening.

In contrast, Modifier 77 is applicable for the distinct physician. It reports with modifier 76 when performed by the same physician, while furnished by a different physician indicates 77.

Modifier 76 vs 59

Modifier 76 applies with service when the same physician performs a similar service or procedure on the same day to the same patient in combination with the other service.

In contrast, Modifier 59 represents the particular service performed by the physician on the same day and is usually not allowed to be billed together on the same day. 

Modifier 76 Examples

The following are the examples when modifier 76 bills:

Example 1

A 39-year-old male with tumors on the lumbar region presented to the emergency department with c/o constant low back pain that started two days ago. The patient is consulted with his primary care physician and suggested to go emergency department. The patient was unable to walk for 1-week. 

He denies trauma, heavy palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, antibiotic use, near-syncope or syncope, changes in stool color, urinary complaints, or any other symptoms. 

The patient took his routine medication. Then, the physician ordered an X-ray of the lumbar region at midnight, showing unremarkable findings. 

Another X-ray performs by the same physician to assess the results again. It reports like 72100 for the first and 72100-76 second service. The patient still has pain in the lumbar region in the morning.

Example 2

A 76-year-old male presents to the office for radiculopathy and stenosis of the lumbar region. He has had severe low back pain since last week. The patient took some medication for pain, but it is getting worse daily. 

The patient Denies trauma, heavy palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, antibiotic use, near-syncope or syncope, changes in stool color, urinary complaints, or any other symptoms. 

CT scans of the lumbar region reveal spondylosis at the L2-L3 level, disc protrusion at the L4-L5 level, and degenerated changes at the L5-S1 area. The physician ordered a steroid injection in the epidural space at the L4-L5 level and got relief from the pain. 

Another CT performs by the same physician to assess the results again. It reports like 72131 for the first and 72131-76 second service. The patient still has pain in the lumbar region in the morning.

Example 3

A 39-year-old male presents to the office with PMH of thyroid cancer presented to the emergency department with c/o constant neck pain that started four days ago and was unable to eat anything for 1-week.

The patient denies trauma, heavy palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, antibiotic use, near-syncope or syncope, changes in stool color, urinary complaints, or any other symptoms, and took his routine medication. 

The patient is consulted with his primary care physician and suggested to go ED. The physician ordered a CT scan of the soft tissues of the neck. The study revealed that multiple thyroid nodules and biopsies were sent to labs to check if the lesion or malignant. 

The same physician performs another CT scan of the neck to assess the results again. Again, it reports like 70490 for the first and 70490-76 second service.

Example 4

A 70-year-old female presented to the office with cervicalgia for one week. The patient took some medication for pain. The pain gets worse with movement and when lying down.

 The patient denies other symptoms such as headache, numbness, urinary problems, nausea, vomiting, and shortness of breath. 

The physical exam revealed swelling in the neck region. The physician ordered a CT of the cervical spine. 

It shows the cervical spine’s degeneration at C1 – C2, C3 – C4, and disk budging at the C4-C5 level. The patient also has spondylosis of the cervical spine. 

The same physician performs another CT scan of the cervical spine to assess the results again. It reports like 72141 for the first and 72141-76 second service. The physician prescribed medicine for pain and treatment.

Example 5

A forty-six-year-old female presents to the emergency department with PMH of hypertension and a family history of heart disease, heart murmur, LBBB dx 1 year ago, migraines, and tested positive for COVID 1 month ago. 

The patient does not receive the vaccine for COVID. She presents to ED c/o constant lip-tingling, lightheadedness, and left-sided chest discomfort since yesterday afternoon, and she Woke this morning with the same symptoms. She also developed left upper extremity tingling and bilateral hand tingling. 

PT Denies headache, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, changes in vision, urinary complaints, or any other symptoms. 

The patient has a strong family history of heart disease—the physician plan to do labs, EKG, X-ray, CT, and MRI of the chest. The same physician performs another CT scan of the cervical spine to assess the results again. It reports like 93010 for the first and 93010-76 second service.

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