Modifier 26
Modifier 26 – Professional Component
Modifier 26 is appended with global billing codes, when physician performs only the professional component service (supervision and interpretation).
Professional component:
Physician portion of services, includes
- Supervision of technician
- Interpretation of results, including written report
Technical component:
- Technologist’s service
- Equipment, film and supplies
Certain services provided to the patient are a combination of both professional component and technical component also called as global procedure code.
When to use Modifier 26 or Modifier TC?
When billing this Professional and Technical component service to the insurance companies:
1) We bill the service either as global procedure (Both professional and technical portions of service), if the service (Both professional and technical component) reported by same organization (provider who interpret the film also have an equipment).
In this case the professional and technical component are not reported or billed separately to the insurance company. Hence, we won’t append modifier 26 or modifier TC to report the claim.
“Or”
2) We will bill this service separately (Professional component separately and the technical component separately by appending modifier 26 and modifier TC respectively), when it’s reported by different organizations.
If we are billing only professional component, then we need to bill the particular procedure code by appending with modifier 26.
If only reimbursing for technical component, then we need to bill the particular procedure code by appending modifier TC.
Examples are shown below:
71030 – 26 (In this radiology service billed with modifier 26, it means only for supervision and final report)
71030-TC (In this radiology service billed with modifier TC, it means only for technician, supplies, equipment)
71030 (Both professional and technical component)
General guidelines and usage of Modifier 26 with examples:
1) Majority of radiology (7XXXX-series) codes do include fee schedule list with separate values for a technical and professional components, then we can bill with appropriate modifier 26 and modifier TC. If the fee schedule doesn’t list separate values for a radiology code with modifier 26 and modifier TC, then the modifier are not appropriate to be used under any circumstances.
For example: If you take the radiation oncology code’s 77261, 77262 77263(Clinical Treatment planning procedure codes), they are professional component codes, so for this code no need to use modifier 26 to define its professional component codes.
2) Some of the surgeries are performed with the radiological guidance. If the surgery performed along with radiological guidance, please check under that particular surgery code in CPT book whether to report that radiological supervision and interpretation separately or not. Because some of the CPT codes radiological guidance is included, in that case we can’t report separately.
Let us see with both scenarios:
a) If the parenthetical note says to report the radiological guidance codes along with surgery code, then report that particular radiology guidance code (with modifier 26) based on the modality (CT, MRI, Fluoroscopic, Ultrasound).
For example: Please check the surgery code 32405 in the CPT book, under that CPT code the parenthetical note states for radiological supervision and interpretation, see 76942, 77002, 77012, 77021.
76942-Ultrasound guidance
77002- Fluoroscopic guidance
77012-CT (Computed Tomography) guidance
77021-MRI (Magnetic Resonance Imaging) guidance
If the biopsy of the lung thru percutaneous performed with the help of radiological guidance, then we need to report the surgery code 32405 and the radiological guidance code (we need to append modifier 26).
We need to select the guidance code of radiology based on the modality (CT, MRI, Fluoroscopic, Ultra sound):
- Suppose if they performed the above surgery with ultrasound guidance, then we need to report as follows:
32405
76942 with modifier 26
Or
- If they perform with CT guidance, then
32405
77012 with modifier 26
b) In some cases there will be no parenthetical note stating “Report radiological supervision and interpretation codes”, because radiological guidance will be a part of the surgery procedure code. So we should report only that particular surgery code.
For example: Please check the CPT code’s 19081, 19082, 19083, 19084, 19085, and 19086
In the above example biopsy of breast thru percutaneous is performed along with radiological guidance, but the radiological guidance is included in the above surgery codes (Please read the description of above codes).
We report only that particular surgery code based on the modality.
3) Trans Esophageal Echocardiography (CPT 93312-93318), we cannot use modifier 26 or modifier TC as we have separate procedure code for each.
Wherein for Trans Thoracic Echocardiography, we can append modifier 26 or modifier TC to report professional or technical component separately, because we do not have separate procedure code for each.
Third Party Administration (TPA) usually reimburse as follows:
- 100% – Global component
- 40% – Professional component (with modifier 26)
- 60% – Technical component (with modifier TC)
For example:
Note: Assume the insurance fee schedule for the radiology code 73080 is $100.
Scenario 1:
Assume patient is coming for elbow x-ray of 3 views, both x-ray and interpretation of report done by same organization or facility.
In this case we are billing the claim globally and get paid 100% of the fee schedule.
73080 = $100
Scenario 2:
Assume patient has done the elbow x-ray of 3 views from ABC organization and the interpretation of report is done from the XYZ organization.
In this case ABC organization will bill only the technical component with modifier TC and get paid 60% of the fee schedule from the insurance company.
73080 with modifier TC = $60
And
XYZ organization will bill only the professional component with modifier 26 and get paid 40% of the fee schedule from the insurance company.
73080 with modifier 26 = $40