Friday, August 6, 2010

Medicare modifier 26 - Professional component usage

Modifier 26  - Professional Component (PC) 'interpretation' Only (separate from technical component for diagnostic, lab or pathology procedures).


Definition:

• Professional Component refers to certain procedures that are a combination of a physician component and a technical component. Using modifier 26 identifies the physician’s component.

Instructions

    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 allowance
        Report in first field as a payment modifier

Correct Use

    Involves global, professional and technical
        E.g. 71010, 71010 26 and 71010 TC
    Place of Service (POS) 21, 22 and 23 only
        Services appended with modifier 26
        Facility pays technical portion with modifier TC
    If 26 and TC are provided in different service locations (enrolled practice locations), the professional and technical must be billed separately

• To bill for only the professional component portion of a test

• To report the physician’s interpretation of a test

• Procedures that have a “1” in the PC/TC field on the MPFSDB




Inappropriate Usage:

• When the same provider performs both the technical and professional components, unless the same provider reports both components and the technical portion is purchased
• Reporting it for re-read results of an interpretation provided by another physician
• Appending it to:
• Technical only procedure codes
• Global test only codes
• Professional component only codes

   Not appropriate with evaluation and management (E/M) or Anesthesia codes

    On or after July 1, 2012, an independent laboratory may not bill TC of a physician pathology service furnished to a hospital inpatient or outpatient

    Cannot use separately if provider performed the global service (In this case, no modifier would be necessary)


Additional Information:

• Identify technical component only codes on the MPFSDB by a “3” in PC/TC.

• Identify global test only codes on the MPFSDB by a “4” in PC/TC.

• Identify professional component only codes on the MPFSDB by a “2” in PC/TC.

• Modifier 26 is a payment modifier reportable in the first modifier field

• Code global services performed without modifiers. Do not report modifiers 26 and TC on the same procedure code on one line of service.



Modifiers 26 and TC

Tufts Health Plan does not add or remove modifiers 26 (professional component) or TC (technical component) to procedure codes requiring the presence or absence of those modifiers in order to apply existing professional and technical component edits. Tufts Health Plan will not compensate for procedure codes requiring modifiers 26 and/or TC if they are not billed in accordance with the current payment policy.

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.

Tufts Health Plan will not compensate for a procedure code requiring modifier TC if a facility bills without modifier TC.

Tufts Health Plan will not compensate for modifier 26 (Professional component) and modifier TC (Technical component) when submitted on the same claim line. Refer to global billing information on page 2 of this policy for additional details.

Note: Tufts Health Plan does not compensate for procedure codes with a PC/TC Indicator of 9 since the concept of PC/TC does not apply.



Payment Conditions for Imaging Services

Generally, imaging services are split into technical and professional components Modifiers (the TC and PC), each separately billable to the local Medicare contractor.

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.

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.

Definitions of Professional and Technical Components and Billing Codes

• The PC of a service is for physician work interpreting a diagnostic test or performing a procedure, and includes indirect practice and malpractice expenses related to that work.

Modifier 26 is used with the billing code to indicate that the PC is being billed.


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.


Modifier 26 is only appropriate in one of the following places of service:

* Hospital inpatient (place of service 21).

* Hospital outpatient (place of service 22).

* Emergency Room (place of service 23).

* Use of Modifier 26 is not appropriate in conjunction with any other place of service code.



Modifier 26 is not appropriate when:

* The same provider performs both the technical and professional components (unless the same provider reports both components and the technical portion is purchased).

* Reporting re-read results of an interpretation provided by another physician.

* Appended to claims that include:

o Technical-only procedure codes.
o Global-test only codes.

* Claims submitted with Modifier 26 that are billed in conjunction with the global component will not be reimbursed.



Here’s an example:

A patient seeks treatment at the Emergency Room (ER) of a hospital for a head injury.

The facility performs a CT of the head without contrast (CPT Code 70450). The film is sent by courier to a noted local radiologist’s office for review. The radiologist  reads/interprets the CT film and seeing no sign of injury or damage calls the hospital’s ER and advises them to release the patient.

The facility will submit a claim for providing the technical component of the service with the following claim elements:

CPT Code 70450
Modifier TC (to indicate the technical component)
POS 23


The radiologist will submit a claim for the reading and interpreting of the results (the professional component PC) of that diagnostic service with the following claim elements:

CPT Code 70450
Modifier 26
POS 23

Billing as Global Service Code

If the global diagnostic service code is billed, the biller (either the entity that took the test, physician who interpreted the test, or separate billing agent) must report the address and ZIP code of where the test was furnished on the bill for the global diagnostic service code. In other words, when the global diagnostic service code is billed, for example, chest x-ray as described by HCPCS code 71010 (no modifier TC and no modifier -26), the locality is determined by the ZIP code applicable to the testing facility, i.e. where the TC of the chest x-ray was furnished. The testing facility (or its billing agent) enters the address and ZIP code of the setting/location where the test took place. This practice location is entered using the ASC X12 837 professional claim format or in Item 32 on the paper claim Form CMS 1500. As explained in D above, in order to bill for a global diagnostic service code, the same physician or supplier entity must furnish both the TC and the PC of the diagnostic service and the TC and PC must be furnished within the same MPFS payment locality.


Separate Billing of Professional Interpretation

If the same physician or other supplier entity does not furnish both the TC and PC of the diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the professional interpretation was furnished in a different payment locality from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician.
 
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 

Enter all applicable modifiers when modifier -99 (multiple modifiers) is entered in item 24d. If modifier -99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a -99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item.



To help ensure the accurate adjudication of claims, we ask that you adhere to the following Modifier 26 guidelines. 

Modifier 26 is only appropriate in one of the following places of service: 

** Hospital inpatient (place of service 21).
** Hospital outpatient (place of service 22).
** Emergency Room (place of service 23).

** Use of Modifier 26 is not appropriate in conjunction with any other place of service code. 

Modifier 26 is not appropriate when:

** The same provider performs both the technical and professional components (unless the same provider reports both components and the technical portion is purchased).

** Reporting re-read results of an interpretation provided by another physician.

** Appended to claims that include:

o Technical-only procedure codes.
o Global-test only codes.

** Claims submitted with Modifier 26 that are billed in conjunction with the global component will not be reimbursed.

The facility will submit a claim for providing the technical component of the service with the following claim elements: 

CPT Code 70450

Modifier TC (to indicate the technical component) POS 23 

The radiologist will submit a claim for the reading and interpreting of the results (the professional component PC) of that diagnostic service with the following claim elements: 

CPT Code 70450 

Modifier 26 POS 23 

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. 

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