CPT modifier 26 designates the service as "interpretation only" and is most commonly submitted with diagnostic tests, including radiological procedures Refer to the Medicare Physician Fee Schedule
Medicare Sustainable Growth Rate
The Medicare Sustainable Growth Rate was a method used by the Centers for Medicare and Medicaid Services in the United States to control spending by Medicare on physician services. President Barack Obama signed a bill into law on April 16, 2015, the Medicare Access and CHIP Reauthorization Act of 2015, which ended use of the SGR. The measure went into effect in July 2015.
What does modifier 26 mean in medical billing?
· Modifier 26 is defined as the professional component (PC). The PC is outlined as a physician's service, which may include technician supervision, interpretation of results and a written report. Use modifier 26 when a physician interprets but does not perform the test. Most radiology codes, including ultrasounds, x-rays, CT scans, magnetic resonance angiography, and …
When to use modifier 26?
· Modifier 26 – Professional Component. Modifier 26 is appended with global billing codes, when physician performs only the professional component service (supervision and interpretation). Professional component: Physician portion of services, includes. Supervision of technician; Interpretation of results, including written report; Technical component:
Can You Bill 85060 with 26 modifier?
· Modifier 26 Usage Guidelines and usage example. Generally, Modifier 26 is appended to a procedure code to indicate that the service provided was the reading and interpreting of the results of a diagnostic and/or laboratory service. To help ensure the accurate adjudication of claims, we ask that you adhere to the following Modifier 26 guidelines.
What is the difference between modifier 26 and modifier TC?
· Indicates physician's interpretation or professional component reported separately (from technical component) for diagnostic, lab or pathology procedures. Check Medicare Physician Fee Schedule (MPFS) Indicator and Descriptor Lists. Certain codes are divided from global with TC/26 modifiers. Technical and professional component fees equal total global …
Does Medicare pay for modifier 26?
Simply Medicare Advantage does not allow reimbursement for use of Modifier 26 or Modifier TC when it is reported with an evaluation and management code.
What does modifier 26 indicate in medical billing?
Generally, Modifier 26 is appended to a procedure code to indicate that the service provided was the reading and interpreting of the results of a diagnostic and/or laboratory service.
When should you use modifier 26?
Modifier 26 is defined as the professional component (PC). The PC is outlined as a physician's service, which may include technician supervision, interpretation of results and a written report. Use modifier 26 when a physician interprets but does not perform the test.
How does modifier 26 affect payment?
The physician who interprets the X-ray submits a claim with modifier 26 appended (e.g., 71045-26). The fee for the service will be split, with approximately 60 percent of payment allotted for the technical component, and 40 percent for the professional component.
What is the difference between TC and 26 modifier?
Technical Component (TC) is assigned when the physician does not own the equipment or facilities or employs the technician. In short, 26 modifier is assigned to pay for the physician services only. While TC modifier is assigned for the facilities used or the equipment used to perform the procedure.
What is the difference between professional and technical component?
The technical component of a charge addresses the use of equipment, facilities, non-physician medical staff, supplies, etc. Technical charges do not include the physician's professional fees, but include the use of all other services associated with the visit.
What is the modifier for bilateral procedure?
modifier 50Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
What is the bilateral procedure rule?
Definition: A surgical procedure is considered bilateral when the same procedure is performed on both sides of the body. Common anatomical sites for bilateral surgical procedures are extremities, eyes, ears, and breasts.
How do you bill a professional component?
The professional component is provided by the physician, and may include supervision, interpretation, and a written report. To claim only the professional portion of a service, CPT Appendix A ("Modifiers") instructs you to append modifier 26, professional component, to the appropriate CPT code.
Why would a TC be billed and not PC?
Modifier TC is used with the billing code to indicate that the TC is being billed. PC and TC do not apply to physician services that cannot be distinctly split into professional and technical components. Modifiers PC and TC may not be used with these billing codes.
What is professional component in medical billing?
The professional component represents the supervision and interpretation of a procedure that is furnished to an individual patient which results in a written narrative report included in the patient's medical record.
How do you bill a technical component?
Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. However, portable x-ray suppliers only bill for technical component and should utilize modifier TC.
What is PC 26?
Modifier 26 – Professional Component (PC) ‘interpretation’ Only (separate from technical component for diagnostic, lab or pathology procedures).
When imaging services are furnished in a leased hospital radiology department to a beneficiary who is neither an inpatient
When imaging services are furnished in a leased hospital radiology department to a beneficiary who is neither an inpatient nor an outpatient of any hospital, both the PC and the TC of the services are payable under the MPFS by the carrier or A/B MAC.
What is the place of service on a radiologist's claim?
The place of service indicated on the radiologist’s claim, in this case, reflects the location where the CT was performed, not the location where the radiologist actually reviewed the film. If the radiologist indicated a place of service of 11 (office), the service 70450 appended with modifier 26 would be denied for an ineligible place of service.
When the physician’s interpretation of a diagnostic test is billed separately from the technical component, as identified by answer
When the physician’s interpretation of a diagnostic test is billed separately from the technical component, as identified by modifier -26, the interpreting physician (or his or her billing agent) must report the address and ZIP code of the interpreting physician’s location on the claim form. If the professional interpretation was furnished at an unusual and infrequent location for example, a hotel, the locality of the professional
Does Tufts pay for modifier TC?
Tufts Health Plan will not compensate for a procedure code requiring modifier TC if a facility bills without modifier TC.
Does Medicare pay for imaging?
Medicare pays under the MPFS for the TC of imaging services furnished to Medicare beneficiaries who are not patients of any hospital, and who receive services in a physician’s office, a freestanding imaging or radiation oncology center, ambulatory surgical center (ASC), or other setting that is not part of a hospital.
Does Tufts Health Plan cover xrays?
Tufts Health Plan will not compensate for diagnostic tests and radiology services having a professional component performed in a home, assisted living facility, nursing facility or skilled nursing facility if those services are billed without modifier 26 to indicate the professional component and transportation of portable x-ray equipment (R0070-R0075) is not also submitted.
Do 26 and TC have to be billed separately?
If 26 and TC are provided in different service locations (enrolled practice locations), professional and technical must be billed separately
Can an independent laboratory bill TC?
An independent laboratory may not bill TC of a physician pathology service furnished to a hospital inpatient or outpatient
Why do we need modifier 26?
Without the Modifier 26, the service is denied so the provider then contacts Novitas to request that Modifier 26 be appended to the procedure code in order to receive payment for the professional component of the service.
What happens if you don't have a TC modifier?
Without the TC modifier, the service will be denied. Because ASCs are not paid for the professional component of services that have both a technical and professional components, the Modifier TC must be appended to indicate the technical component only.
What is a 26 modifier?
The 26 modifier is a particularly unique coding tool in the billing and coding world. As we know, a modifier explains to payers the specific work that was done by a physician during the treatment of a patient. This concept is taken a step further when modifier 26 is needed. This is because modifier 26 can only be used for certain kinds ...
How to use modifier 26?
Examples of when to use modifier 26: 1 A sleep center performs polysomnography for a patient. A physician not associated with the sleep center facility interprets the findings of the test. This physician would append modifier 26 to 95811 to represent her interpretation of the polysomnography. 2 A pregnant patient presents to the ER with premature contractions. The ultrasound performed in the hospital detects abnormalities in the pregnancy. The patient is referred to a specialist for follow-up, and the hospital imaging report is sent with the patient for further review. The specialist reviews and interprets the ER ultrasound, so the specialist would use modifier 26 on the ultrasound CPT to represent their interpretation-only service of the report. 3 A treating physician orders a test from an outside laboratory for his patient. The lab’s pathologist then provides their written interpretation to the attending physician. In this case, the pathologist could bill the procedure 83020 with a modifier 26 representing their interpretation of the test.
What modifier do sleep centers use?
A sleep center performs polysomnography for a patient. A physician not associated with the sleep center facility interprets the findings of the test. This physician would append modifier 26 to 95811 to represent her interpretation of the polysomnography.
What is modifier 26 on an ultrasound?
The patient is referred to a specialist for follow-up, and the hospital imaging report is sent with the patient for further review. The specialist reviews and interprets the ER ultrasound, so the specialist would use modifier 26 on the ultrasound CPT to represent their interpretation-only service of the report.
Why is modifier 26 needed?
This is because modifier 26 can only be used for certain kinds of procedures which include a “professional component”. For this reason, knowing when to appropriately use the 26 modifier frequently causes confusion among billers.
What modifier is used for 83020?
In this case, the pathologist could bill the procedure 83020 with a modifier 26 representing their interpretation of the test.
Can a treating physician bill for 83020?
To illustrate incorrect use, the treating physician in the example above cannot bill 83020- 26 themselves after they review the pathology report, because the pathologist has already interpreted the test. The treating physician can include her own interpretation in her medical decision-making, but should not bill separately for it.
What is the part of the reimbursement that you are not getting?
The part of the reimbursement that you "are not getting" is the part that is meant to reimburse the facility for the cost of purchasing and maintaining the equipment. If he wants to buy his own equipment, open a radiology center, and interpret the results, then he can get the "full" reimbursement! P.
Is modifier 26 an interpretation modifier?
I apologize for offering an incomplete reply. Modifier-26 is not "just" an interpretation modifier. It is the "professional componant" modifier. That means it covers ALL services performed by the physician in relation to the code it was attached to. You are using it correctly, and getting paid the correct amount. I know this is not the answer you were hoping for, but it is the only one I have.
