Billing and Coding Article

Billing and Coding: Repeat or Duplicate Services on the Same Day

A53482

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10112 - MAC B	J - J	Alabama
Palmetto GBA	A and B MAC	10212 - MAC B	J - J	Georgia
Palmetto GBA	A and B MAC	10312 - MAC B	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11202 - MAC B	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11302 - MAC B	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11402 - MAC B	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11502 - MAC B	J - M	North Carolina

Article Information

General Information

Article ID
A53482

Article Title
Billing and Coding: Repeat or Duplicate Services on the Same Day

Article Type
Billing and Coding

Original Effective Date
10/01/2015

Revision Effective Date
10/31/2019

Revision Ending Date
N/A

Retirement Date
N/A

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CMS National Coverage Policy

Medicare Claims Processing Manual, Pub. 100-04, Chapter 34

Title XVIII of the Social Security Act, §1833(e)

Article Guidance

Article Text

Claims for multiple and/or identical services provided to an individual patient on the same day, may be denied as duplicate claims if Palmetto Government Benefit Administrators (GBA) cannot determine that these services have, in fact, been performed more than one time. Filing claims properly the first time will reduce denials.

Many providers and billing departments re-file claims without allowing sufficient time for the original claim to process. Refilling a claim before the original claim has processed can cause further delays in processing and payment. One submission of a claim is all that is required. If you have not received payment after 30 days and are concerned about your payment, please use the Palmetto GBA interactive voice response (IVR) or the online provider services (OPS) for an electronic claims status inquiry function.

A denial should be expected if identical duplicate services are submitted for the same date of service. Should a correction of a previously submitted claim be needed, do not submit the correction as a new claim. Palmetto GBA can reopen claims for minor corrections. Claims denied as “not medically necessary” cannot be reopened at the claims processing level after a denial for that reason has been issued. An appeal (redetermination) may be requested for services denied as “not medically necessary” or for other issues beyond minor corrections. Additional documentation in support of the service(s) provided should be submitted with the appeal request. Please refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 34 for detailed instructions regarding a reopening vs. an appeal.

To ensure correct processing of your claim, please consider the following:

• Submit services on one claim using the Days/Units fields and appropriate modifier.
• Please be sure the correct modifiers are submitted on the claim when multiple identical services are submitted in order to identify these services as separate services and not duplicate billing of the same service. A denial can be expected if the same service is submitted on more than one claim or more than one claim line for the same date of service.

Example:
The patient receives two chest x-rays on 10/1/15 which are interpreted by the same physician. The first interpretation is performed at 10 a.m. and the interpretation of the second x-ray is performed at 1:30 p.m.

Submit as:

CPT Code/Modifier Days/Units
10/1/15 71020-26 1
10/1/15 71020-26-76 1

Modifiers
Failure to submit appropriate modifiers may result in delay of payment or denial of service(s). When a modifier is used to indicate a repeat service, as in the above example, the first service should be submitted without the -76 modifier and the repeat service(s) should include the -76 modifier(s).

Site Modifiers:
•Use site modifiers (e. g. RT, LT, T1) as appropriate.

Example:
The patient receives a percutaneous tenotomy on the second digit and the fourth digit of the left foot by the same physician on the same day.

Submit as:
Date of Service CPT Code/Modifier Days/Units
10/1/15 28010-T1 1
10/1/15 28010-T3 1

Identical services being repeated should be submitted using CPT modifier 76, 77, or 91.

•CPT Modifier 76: 'Repeat procedure by same physician: The physician may need to indicate that a service was repeated the same day subsequent to the original service. This modifier indicates the difference between duplicate services and repeated services.

•CPT Modifier 77 'Repeat procedure by another physician': A physician may need to indicate that he or she repeated a service performed by another physician on the same day.

Example:
Patient receives two EKGs on 10/1/15. The first EKG is taken at 10 a.m. and Dr. A performs the interpretation. The second EKG is taken at 1:30 p.m. and Dr. B performs the interpretation.

Submit as:

Claim #1 Dr. A

Date of Service CPT Code Days/Units
10/1/15 93010-26 1

Claim #2 Dr. B

Date of Service CPT Code Days/Units
10/1/15 93010-26-77 1

•CPT Modifier 91 'Repeat clinical diagnostic laboratory test': It may be necessary to repeat the same laboratory test on the same day to obtain multiple test results. In this case CPT modifier 91 should be used. This modifier may not be used when tests are repeated to confirm initial results due to testing problems with equipment or specimens. Tests that include multiple specimens being collected at different times (e.g., glucose tolerance) should be submitted using the appropriate code for the test and should not be submitted as repeated tests.

Example:

The patient had two folic acid tests performed on the same day.

Submit as:

Date of Service CPT Code/Modifier Days/Units
10/1/15 82746 1
10/1/15 82746-91 1

Response To Comments

Number	Comment	Response
1

Coding Information

CPT/HCPCS Codes

N/A

CPT/HCPCS Modifiers

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Group 1

(8 Codes)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
26	PROFESSIONAL COMPONENT: CERTAIN PROCEDURES ARE A COMBINATION OF A PHYSICIAN COMPONENT AND A TECHNICAL COMPONENT. WHEN THE PHYSICIAN COMPONENT IS REPORTED SEPARATELY, THE SERVICE MAY BE IDENTIFIED BY ADDING THE MODIFIER -26 TO THE USUAL PROCEDURE NUMBER OR THE SERVICE MAY BE REPORTED BY USE OF THE FIVE DIGIT MODIFIER CODE 09926.
76	REPEAT PROCEDURE BY SAME PHYSICIAN: THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS REPEATED SUBSEQUENT TO THE ORIGINAL PROCEDURE OR SERVICE. THIS CIRCUMSTANCE MAY BE REPORTED BY ADDING THE MODIFIER -76 TO THE REPEATED PROCEDURE OR SERVICE OR THE SEPARATE FIVE DIGIT MODIFIER CODE 09976 MAY BE USED.
77	REPEAT PROCEDURE BY ANOTHER PHYSICIAN: THE PHYSICIAN MAY NEED TO INDICATE THAT A BASIC PROCEDURE OR SERVICE PERFORMED BY ANOTHER PHYSICIAN HAD TO BE REPEATED. THIS SITUATION MAY BE REPORTED BY ADDING MODIFIER -77 TO THE REPEATED PROCEDURE/SERVICE OR THE SEPARATE FIVE DIGIT MODIFIER CODE 09977 MAY BE USED.
91	REPEAT CLINICAL DIAGNOSTIC LABORATORY TEST: IN THE COURSE OF TREATMENT OF THE PATIENT, IT MAY BE NECESSARY TO REPEAT THE SAME LABORATORY TEST ON THE SAME DAY TO OBTAIN SUBSEQUENT (MULTIPLE) TEST RESULTS. UNDER THESE CIRCUMSTANCES, THE LABORATORY TEST PERFORMED CAN BE IDENTIFIED BY ITS USUAL PROCEDURE NUMBER AND THE ADDITION OF THE MODIFIER '-91'. NOTE: THIS MODIFIER MAY NOT BE USED WHEN TESTS ARE RERUN TO CONFIRM INITIAL RESULTS; DUE TO TESTING PROBLEMS WITH SPECIMENS OR EQUIPMENT; OR FOR ANY OTHER REASON WHEN A NORMAL, ONE-TIME, REPORTABLE RESULT IS ALL THAT IS REQUIRED. THIS MODIFIER MAY NOT BE USED WHEN OTHER CODE(S) DESCRIBE A SERIES OF TEST RESULTS (E.G., GLUCOSE TOLERANCE TESTS, EVOCATIVE/SUPPRESSION TESTING). THIS MODIFIER MAY ONLY BE USED FOR LABORATORY TEST(S) PERFORMED MORE THAN ONCE ON THE SAME DAY ON THE SAME PATIENT.
LT	LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)
RT	RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)
T1	LEFT FOOT, SECOND DIGIT
T3	LEFT FOOT, FOURTH DIGIT

ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
10/31/2019	R7	This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Under *CMS National Coverage Policy* section added regulations. Under *CPT/HCPCS Modifiers Group 1: Codes* added modifiers 26, 76, 77, 91, T1, T3, LT, RT. Formatting, punctuation and typographical errors were corrected throughout the article.
05/24/2018	R6	Under *Article Text* first sentence added the verbiage “Government Benefit Administrators” in front of the acronym “GBA”.
02/26/2018	R5	The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
05/26/2016	R4	Revision History defined in Revision History #2 is incorrect. The correct version for Revision History #2 should read “Under Article Guidance, added “and/or” and “in fact” to the first paragraph. Added clarification related to the refiling of claims. IVR and OPS were defined. Under *Article Text* instructions were provided in the first paragraph related to corrections of previously submitted claims and medical necessity denials. Subsequent paragraphs and sections detail the billing of services that may appear to be duplicate services, the use of modifiers, and units submitted on claims.” The effective date is unchanged 5/26/16.
05/26/2016	R3	Under *Revision Effective Date* corrected the date to read 05/26/2016. The effective date for Revision 2 should correctly read 05/26/2016.
05/19/2016	R2	Under *Article Text* the information contained in the second paragraph was transferred into the first paragraph. Billing information and an example of completing the CMS 1500 in paragraph four was merged into the third paragraph and “HFCA” 1500 was updated to "CMS" 1500. Information that Evaluation and Management codes are separately reimbursed was corrected to read that these services are not separately payable unless the practitioner provides a significant, separately identifiable service. The pharmacy compounding fee was removed from the fourth paragraph. The “Medication Price” list was deleted. Under *Statutory Requirements URL(s)* the URLs were removed. Under *Rules and Regulations URL(s)* the URL was removed. Under *CMS Manual Explanations URL(s)* the URL was removed.
10/01/2015	R1	Reviewed for Annual Validation.

Associated Documents

Updated On	Effective Dates	Status
10/23/2019	10/31/2019 - N/A	Currently in Effect	You are here
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Keywords

Duplicate
Services
Radiology
Same Day

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Billing and Coding: Repeat or Duplicate Services on the Same Day

Document Note

Note History

Contractor Information

Article Information

General Information

CMS National Coverage Policy

Article Guidance

Response To Comments

Coding Information

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Group 1

CPT/HCPCS Modifiers

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

ICD-10-PCS Codes

Group 1

Additional ICD-10 Information

Bill Type Codes

Revenue Codes

Other Coding Information

Group 1

Coding Table Information

Revision History Information

Associated Documents

Keywords

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