Modifier 26 Professional Component - Usage and Reimbursement
Modifier -26 identifies the physician's or professional component of a two-component (professional and technical) service. The physician component is reported separately when the physician provides only the supervision and interpretation portion of the procedure. The technical component includes reimbursement for the facility, equipment, film processing, and the technician
Appropriate Usage
To bill for only the professional component portion of a test when the physician provides only the supervision and interpretation portion of the procedure.
Procedures that have a "1" in the PC / TC field on the MPFSDB - The indicator 1 (Diagnostic tests or radiology services) identifies codes that describe diagnostic tests, e.g., pulmonary function tests, or therapeutic radiology procedures, e.g., radiation therapy. These codes generally have both a professional and technical component. Modifiers 26 and TC can be used with these codes. The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense.
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
Do not append Modifier 26 to Technical only procedure codes, Example: CPT 93005
Do not append Modifier 26 to Global test only codes, Example: CPT 93000
Do not append Modifier 26 to Professional component only codes. PC / TC indicator 2 of MPFSDB denotes Professional component only codes that identifies stand alone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test only and another associated code that describes the global test.
An example of a professional component only code is 93010, Electrocardiogram; interpretation and report. Modifiers 26 cannot be used with these codes.
Reimbursement:
The reimbursement split for a two-component service is 60 percent technical and 40 percent professional; however, this split varies by payer, geographic locations, and CPT code.
Know more about Professional Component (PC) / Technical Component (TC) Indicators '0 to 9'
Return to List of all Modifiers
Popular Posts
-
Modifier - as the name implies a modifier will modify a service / procedure or an item under certain circumstances for appropriate reimbur...
-
An OPPS payment status indicator is assigned to every HCPCS code. The status indicator identifies whether the service described by the H...
-
Claim Adjustment Reason Codes (CARC) CO-22 or PR-22 This care may be covered by another payer per coordination of benefits. CO-19 This is...
-
Therapeutic activities are considered medically necessary for patients needing a broad range of rehabilitative techniques that involve ...
-
This procedure is medically necessary only when it requires the professional skills of a therapist, is designed to address specific ne...
-
Ambulance transportation is a covered service when the patient’s condition is such that the use of any other method of transportation would...
-
Health benefit payers, including Medicare, are limited to use of those internal and external code sets identified in the implementation gui...
-
Mohs surgery, also known as chemosurgery, created by a general surgeon, Dr. Frederic E. Mohs, is performed to remove complex or ill-defi...
-
AAPC’s Certified Professional Coder (CPC) credential is the gold standard for medical coding in physician office settings and held by more ...
-
CIGNA will adopt a common time frame for health care professionals to follow for submitting claims to CIGNA. Except where state law requir...