When you’re only claiming the code’s professional portion, include this modifier.
If your physician performs a service in a location where he doesn’t pay the rent, you should be on the lookout for a potential modifier 26 (Professional component) coding situation.
Why? Often, a CPT® code’s relative value units (RVUs) are broken down into a technical component and a professional component; you’ll append modifier 26 when your physician only provides the professional component, explains Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med, a medical auditing, coding and education organization in Pittsburgh, Pa.
Coders employ modifier 26 most commonly in “office or outpatient facilities when the equipment is the property of the clinic or facility, and not [your] physician,” Hauptman explains.
If you don’t use modifier 26 when appropriate, you’ll open your practice up to accusations of overcoding and all sorts of potential red tape. Check out this quick advice on using modifier 26 appropriately on every claim.
Though modifier 26 encounters can occur in any setting, these spots see many modifier 26 claims, confirms Yvonne Bouvier, CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind.:
Example: An ED physician performs a FAST (focused assessment with sonography for trauma) exam, which includes an echocardiography (ECG) and a limited abdominal ultrasound. For the claim, you’d need to append modifier 26 to both 93308 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, follow-up or limited study) and 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]) to show that you are only coding for your physician’s services, not the FAST exam equipment.
Modifier TC: In the above example, the owners of the equipment your physician used will report 93308 and 76705 — both with modifier TC (Technical component) appended. This shows the payer that the equipment owners are only claiming the technical portion of the CPT® code.
Another common modifier 26 scenario is x-rays. Let’s say your physician performs a two-view thoracic spine x-ray. Unless she owns the x-ray equipment, you’d report 72070 (Radiologic examination, spine; thoracic, 2 views) with modifier 26 appended.
While many modifier 26 encounters occur outside of your practice walls, there is no site of service requirement to use the modifier. And there are also codes, mostly in the radiology section and medicine testing sections of CPT®, that are divided into professional and technical components. Some of these codes include:
Best bet: When you’re coding for one of these services, have modifier 26 at the ready in case you need to use it.