26 Modifier

Modifier 26 Description, Uses, Guidelines & Examples (2022)

Modifier 26 appends with service when the Physician performs the Professional component only.

Modifier 26 Description

Modifier 26 indicates the professional component of the service performed by the Physician. The Professional component is when the Physician Interprets the report, technician supervision, Interpretation of results, and a written report. The service is performed by the technician, not by the Physician.

Modifier 26 appends with the combination of procedures furnished by the Physician or other skilled professional such as a technician. The technician may perform the service, and the Physician may or may not supervise but interpret the result and sign the report. Both services differentiate between the modifier TC and 26.

Global billing plays a significant role when assigning 26 or TC with the service. 26 Modifier and TC bills separately for the service and get reimbursement separately for each component. For example, the Facility only bills the service for the technical component with the TC modifier. In contrast, The Physician bills for the professional component only.

The Physician provides both the technical (component (equipment, supplies, and technical support) and professional (supervision, Interpretation, report). Therefore, it would be considered a single-line claim for global billing and bills without 26 or TC modifier. The service may provide to the patient in an office or private clinic. 

Modifier 26 frequently bills for radiological services, also with pathology and laboratory and Medicine section CPT when appropriate.

26 Modifier is irrelevant to surgical procedures and evaluation and management procedure codes (99202-99499). Therefore, if CPT code Descriptors include the professional component in the CPT code book, It is inappropriate to attach modifier 26. 

26 modifier

What Is Modifier 26?

Modifier 26 signifies the professional component of the service performed by the Physician. The Professional component is when the Physician Interprets the report, technician supervision, Interpretation of results, and a written report. The service is performed by the technician, not by the Physician.

When To Use Modifier 26

Modifier 26 appends with the service when the Physician does not own the equipment and service furnished in the hospital facility. 

26 Modifier appropriates when the Physician performs Interpretation of a test, which is separate, distinct, written, and signed or may perform under the supervision of the technician.

Modifier 26 Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.  

Modifier 26does not apply to evaluation and management procedures (99201-99499). It is appropriate to report with E/M Modifiers 25, 24, 57, etc.

It is inappropriate to report 26 when the same providers perform both technical and professional components unless The provider owns the equipment or buys the technical portion. 

Modifier 26 is inappropriate for bills when the Physician reinterprets an already interpreted result by another Physician.

26 Modifier is inappropriate for bills when CPT code descriptors include both professional and technical components and for global test-only codes.

Modifier 26 is inappropriate for bills When CPT code descriptors include the professional component only. 

Modifier 26 is inappropriate for bills When CPT code descriptors include Technical components only. For instance, CPT 93005 includes tracing only but not the Interpretation of results and reports. In contrast, CPT 93010 bills for Interpretation and report only (Physician). 

The Facility or Hospital bills modifier TC for the technical component only, while the Physician appends 26 with the service to avoid duplicates. It may also result in early reimbursements from the insurance or third-party payer. 

Modifier 26 and TC

Modifier TC bills for the service when the technician performs the service, but the Physician interprets the test or result. It includes Technical components only, such as supplies, personnel, the provision of all equipment, costs related to the procedure’s performance, and the practice and the malpractice expense.

The Facility uses a TC modifier to reimburse the technical portion of the service or technical component of the CPT code. In addition, the Facility or Practices use a TC modifier to compensate for supplies, equipment, and clinical staff (technicians).

In contrast, Modifier 26 appropriates when the Physician performs Interpretation of a test, which is separate, distinct, written, and signed or may perform under the supervision of the technician.

Modifier 26 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.

Modifier 26 Examples

The following are the example modifier 26 when bills:

Example 1

A 38-year-old male presents to ED with a chief complaint of dizziness. The patient reports vertigo began one day ago. Vertigo began while at home when he stood up. 

The patient describes the course of vertigo as abrupt, and The dizziness is currently 6/10. Vertigo worsened by standing, head movement, and movement. The vertigo is not worsened by breathing or lying supine. 

Anti-vertigo meds alleviate vertigo. Vertigo is associated with nausea, vomiting, and gait instability. Vertigo is not associated with a vision change. 

The patient is morbidly obese ha a higher risk of heart disease. Therefore, the Physician ordered multiple diagnostic tests ECG, CMP, CBC, CT, MRI, and X-ray of the head, chest, and spine.

The Physician performs a Head CT in the Facility and works as an employee in the hospital. He provides the supervision and Interpretation of the report. Therefore, it may bill as 70450 with modifier 26. In contrast, The Physician performs in a private clinic or office and may bill as 70450 without 26 Modifier.

Example 2

A 30-year-old female with no PMH is coming in for intermittent chest pain exacerbated by left-arm movement but is non-exertional and has abdominal pain. 

Given the positional nature of chest pain, I suspect a musculoskeletal cause. Differential includes, but is not limited to MSK-related pain/costochondritis/ ACS Pt is very well appearing with routine physical exam and vitals. She is not having any pain right now. 

The patient was not getting better by medication. So physicians ordered a CT, Abdominal Ultrasound, chest X-ray, and EKG to confirm that the heart was functioning correctly. 

For example, The Physician performs the Abdominal US in the Facility and works as an employee in the hospital. He provides the supervision and Interpretation of the report. Therefore, it may bill as 76700 with modifier 26. In contrast, The Physician performs in a private clinic or office and may bill as 76700 without 26.

Example 3

Forty-six-year-old female with PMH of hypertension and a family history of heart disease heart murmur, LBBB dx 1 year ago, migraines, tested positive for COVID 1 month ago. 

Since yesterday afternoon, she has presented to ED c/o constant lip-tingling, lightheadedness, and left-sided chest discomfort. She woke with the same symptoms and developed left upper extremity and bilateral hand tingling. The patient did not get vaccinated for COVID. 

The patient Denies headache, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, changes in vision, urinary complaints, or any other symptoms. 

The patient has a family history of heart diseases—the physician plan to do labs, EKG, X-ray, CT, and MRI of the chest.

For Instance, The Physician performs a chest MRI in the Facility and works as an employee in the hospital. He provides the supervision and Interpretation of the report. Therefore, it may bill as 71550 with modifier 26. In contrast, The Physician performs in a private clinic or office and may bill as 71550 without 26 Modifier.

Example 4

A 27-year-old male with PMH Systolic/Diastolic CHF (EF <15% 7/23/21, s/p AICD), COVID x2, s/p TAVR, CAD, CKD, PAD, hypothyroidism for shortness of breath. He has developed progressively worsening shortness of breath for four days. 

He noticed worsening SOB laying on his right side and with exertion. He takes his vitals daily and weighs himself daily. 

He typically weighs 171lbs but has seen a 3.5lb increase in his weight to 174.5lbs over this past week, which prompted him to take one dose of alprazolam 30mg. Unfortunately, he noticed a minimal improvement in his symptoms with the alprazolam. 

He notices a substernal discomfort when he has episodes of coughing with phlegm. The pain is not alleviated with rest and not exacerbated with exertion. He has also noticed increasing yellow phlegm production, cough, nasal congestion, and rhinorrhea. 

The Physician has respiratory problems along with Heart issues. Diagnostic studies show that patient had an irregular heartbeat and suggested cardioversion. The Physician ordered an X-ray of the chest, EKG, Labs, CT, and MRI to diagnose for further treatment.

The Physician performs a chest CT in the Facility and works as an employee in the hospital. He provides the supervision and Interpretation of the report. Therefore, it may bill as 71250 with 26. In contrast, The Physician performs in a private clinic or office and may bill as 71250 without modifier 26.

Example 5

A 40-year-old female presented office for nausea, vomiting, diarrhea, and chest pain. The patient denies any extremity pain, swelling, or headache in the system review. 

Physical exam revealed that the patient had an irregular heartbeat, shortness of breath, and fluid accumulation in the upper extremity, more likely edema. A physical exam strongly suggests ruling out heart-related diseases. The Physician decides to do an X-ray, ECG/EKG, CTA, and MRA of the chest. 

Diagnostic studies show that patient had an irregular heartbeat and suggested cardioversion. EKG revealed that the patient is tachycardic. The Physician has consulted with the cardiologist for further treatment of the patient.

For example, The Physician performs a chest X-ray in the Facility and works as an employee in the hospital. He provides the supervision and Interpretation of the report. Therefore, it may bill as 71046 with 26 Modifier. In contrast, The Physician performs in a private clinic or office and may bill as 71046 without modifier 26.

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