Last Modified: 3/13/2024
Location: FL, PR, USVI
Business: Part B
Duplicate claim denials continue to be one of the top billing errors. Duplicate submission of Medicare claims causes an increase in cost, valuable time, and resources for you as well as First Coast.
A duplicate denial indicates more than one claim was submitted for the same service, for the same patient, for the same date of service. In most instances, the claim was already processed and paid, or it is an exact duplicate of a previously submitted claim.
Did you know that there are several different pieces of claim information that can be reported to avoid a duplicate denial?
Review your medical record documentation to determine if a modifier is appropriate. Some examples include:
• Use
modifier 76 to indicate a procedure or service was repeated after the original procedure or service.
• Report a narrative description indicating the reason for the repeat procedure in item 19 of the CMS-1500 claim form or the EDI equivalent.
• Use
modifier 77 to indicate repeat clinical diagnostic laboratory was repeated by another physician.
• Report a narrative description indicating the unusual circumstance for the use of the modifier in item 19 of the CMS-1500 claim form or the electronic equivalent.
• Use modifier 91 to indicate any repeat clinical diagnostic laboratory test.
• Consider using an anatomical modifier to designate the area or part of the body on which the procedure is performed:
• E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
• The
JW modifier is only applied to the amount of drug or biological that is discarded. The discarded drug should be billed on a separate line with the JW modifier.
• XE – “Separate encounter, a service that is distinct because it occurred during a separate encounter” -- use this modifier only to describe separate encounters on the same date of service.
• XS – “Separate Structure, a service that is distinct because it was performed on a separate organ/structure.”
• XP – “Separate Practitioner, a service that is distinct because it was performed by a different practitioner.”
• XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.”
• Report
modifier 59 to indicate a distinct procedural service and is independent from other procedures on the same day.
• This may represent a different session or patient encounter, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury (or area of injury in extensive injuries)
• Best practice is to review the terminology of the X modifiers vs. 59. Modifier 59 is the modifier of last resort.
• Bill all services performed on one day on the same claim.
• Report each service on a separate line.
• More than one line with
modifier 59 appended to the same procedure code requires submission of supporting information/documentation on the claim:
• Block 19 of the CMS-1500 claim form or electronic equivalent.
• Do not report modifier 59:
• When another established, more descriptive modifier is available.
• If submitted with E/M codes 99202-99499.
• When documentation does not support the separate and distinct status.
• When used to indicate multiple administrations of injections of the same drug.
Report diagnoses to reflect the service as separately identifiable from the other service(s) reported on the same day.
• Services should be reported using the diagnosis codes to the highest level of specificity for the date of service.
• When multiple services are performed, enter the primary reference number/letter for each service.
• If the subsequent service is not related to the first, use the diagnosis related to each procedure on the individual lines to show they are separate and distinct.
All claims require the complete address and ZIP code of where the services were rendered in item 32 of the CMS-1500 claim form or the electronic equivalent. Please ensure that this information is completed.
Taking the following steps can help you eliminate receiving a duplicate denial.
• Where appropriate, use a unit of service multiplier rather than billing services on individual lines.
• Example: Drug codes - bill according to the code/dosage and add a multiplier on the claim to show the appropriate unit/dosage.
• Whenever possible, coordinate care with other physicians treating your patient on the same date.
• Allow 30 days from the claim receipt date for the claim to process before resubmitting a subsequent claim for the same service(s).
• Before submitting a new claim, review your
remittance advice for the previously processed claim.
• Verify the reason the initial claim did not allow payment.
• Use the claims correction feature in
SPOT 
to adjust a previously processed claim.
• Use the
Reopening Gateway to complete a claim correction for previously processed claims.
Note: Many providers will refile a claim to correct a previously denied claim. This resubmission can cause an unnecessary duplicate denial when the initial claim processed correctly.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
to provide greater reporting specificity in situations where modifier 59 was previously reported
