Medicaid billing guidelines for repeat procedures on the same day

To ensure compliance with DHS Medicaid billing policies and avoid claim denials, providers must follow specific guidelines when billing for repeat procedures performed on the same date of service (DOS).

When you submit 2 claims for the same procedure code on the same DOS, the second claim is typically denied as a duplicate, even if the service was legitimately repeated. This is especially common for diagnostic procedures like radiology. For most repeat services, include multiple claim lines on a single claim using appropriate modifiers.

For certain repeat services, like emergency room (ER) visits, that can’t be indicated on a single claim, appropriate modifiers should be used on subsequent claims.

Use modifiers to indicate repeat services

To differentiate repeat procedures and ensure proper reimbursement, use appropriate modifiers and place them in the first position on the claim line.

Billing scenarios and guidelines

1. ER visits – twice in one day

• Issue: Two ER claims with identical procedure codes on the same DOS will result in the second claim being denied.
• Guideline:
• Bill the first ER visit normally.
• For the second ER visit, include the distinct or repeat procedure modifier in the first position on the claim line.
• This signals that the service was repeated and should be processed accordingly.

2. Radiology example – multiple identical procedures

• Scenario: Procedure code 71045 (e.g., chest X-ray) performed 4 times on the same day.
• Guideline:
• Bill all instances on a single claim.
• Use multiple claim lines, each with the appropriate modifier in the first position.
• Example:
• Line 1: 71045-26 × 1 (initial procedure)
• Line 2: 71045-76-26 × 3 (repeat procedures with modifier 76 for repeat service and 26 for professional component)

Best practices for repeat procedure billing

• Always use modifiers to indicate repeat or distinct services.
• Place the modifier in the first position on the claim line.
• Consolidate repeat procedures on a single claim when possible.
• Use multiple service lines to reflect each occurrence of the procedure.

Why it matters

Following these guidelines:

• Prevents duplicate claim denials
• Aligns with Medicaid billing and encounter data standards
• Supports efficient claims processing and accurate reimbursement