CPT codes billed with modifier 76 are often erroneously denied as duplicates. There is a way to reduce the number of claims denied when applying this modifier. The solution is documenting additional information in box 19 of the CMS-1500 form to explain the medical necessity for performing additional procedures.
For example, by including the words “four separate lesions shave removed” in box 19, the frequency of denials for multiple lesions will decrease significantly. Billing staff should also be familiar with the anatomical modifiers (FA through F9) and use those instead of 76, if applicable. If four shave removals (e.g., CPT codes 11300-11306) were performed on the fingers, you would use the above modifiers instead of modifier 76. Be sure to include text in box 19 to support performing the number of lesions treated.
Lastly, keep an eye on Medically Unlikely Edits (MUE) for the procedures you are doing on the same patient for the same date of service. MUEs refer to carrier-set thresholds for specific CPT codes for same-day services. MUEs lists are updated quarterly. For most CPT procedure codes related to Dermatology, the update will indicate the number of units that are allowed for reimbursement for same-day services.
Even though the appropriate modifiers are applied and notations are made in box 19, there may still be carriers that deny claims and request additional information that supports the medical necessity for each of the procedures performed during that visit.
For information on the appropriate use of Modifiers 76 visit NGS Medicare
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The Billing Process
After 27 years of perfecting billing processes, Inga Ellzey continues to be the nation’s leading expert in dermatology billing. Our billing service serves over 100 dermatology practices in 37 states without utilizing any offshore labor. Our goal is to make sure that you and your patients receive the most competent and professional service available on the market today.