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'

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