Preventing duplicate claim denials

Claim system edits search for duplicate and repeat services within paid, finalized, pending and same claim details in history. Therefore, unless applicable modifiers are included on your claim, the edits may detect same, or similar, duplicate services. Please share this information with your billing companies, vendors and clearing houses.

To prevent duplicate claim denials and ensure you are billing correctly, review your billing software and procedures. Some services on a claim may appear to be duplicates when, in fact, they are not.

Use modifiers, as applicable, to identify procedures and services that are not duplicates. A complete list of modifiers can be found in the Current Procedural Terminology (CPT®) codebook. The following are a few examples of modifiers that may be used to indicate repeat, or distinct, procedures and services:

• Modifier 76 may be used to indicate a repeat procedure or service by the same provider, subsequent to the original procedure or service.
• Modifier 91 may be used to indicate repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.
• Modifier 59 may be used to identify procedures or services that are normally reported together but are appropriate to be billed separately under certain circumstances. Modifier 59 indicates a procedure or service by the same provider, distinct or independent from other services, performed on the same day.