Effective Date: October 14, 2019

Purpose:
Provide guidelines for application and payment of modifier -76 when appropriately billed by professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Modifier -76: Used to indicate that a procedure or service was repeated subsequent to the original procedure or service by the same provider ID on for the same member on the same date of service or within the post-operative period.

Policy:
Horizon NJ Health shall consider for reimbursement procedures appended with modifier -76 only in instances where the same procedure is billed by the same provider NPI, for the same member, on the same date of service or within the postoperative period of the original service.

Procedure:
Horizon NJ Health shall consider for reimbursement procedures appended with modifier -76 when the same procedure code has been billed by the same Provider NPI for the same provider NPI, for the same member, on the same date of service, or within the postoperative period”. Horizon NJ Health shall apply the applicable Horizon NJ Health fee schedule to procedures appropriately appended with modifier -76.

Horizon NJ Health shall deny procedures appended with modifier -76 when the same procedure code has not been billed by the same provider NPI for the same member on the same provider NPI, for the same member, on the same date of service, or within the postoperative period”.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual Chapter 12- Physicians/Nonphysician Practitioners cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services