DEXA Coding 101: Append -26 for Second Opinions

Recoup payment for your endocrinologist's interpretation and report
You've listed the correct dual energy x-ray absorptiometry (DEXA) CPT code on your claim, linked it to a covered diagnosis and confirmed your payer's frequency guidelines, so your claim is as good as paid, right? Not so fast. In some cases, you may have to append modifier -26 to collect payment for your DEXA claims.

You should append modifier -26 (Professional component) to your DEXA services in the following two circumstances, says Jeff Fulkerson, BA, CPC, senior certified coder in the radiology department of Emory Health Care in Atlanta:

Some endocrinology practices may have an arrangement with a hospital or other DEXA scan facility in which the DEXA facility bills only for the technical component and then sends the results to the endocrinologist for interpretation. In this situation, you should select the appropriate DEXA scan code and then append modifier -26 to indicate that your physician deserves payment for the professional component only, Fulkerson says.
A patient may seek a second opinion on her DEXA scan films. If a patient visits your endocrinologist and asks him to interpret the results a second time, you can bill the appropriate DEXA scan code with modifier -26 because your endocrinologist is performing the service on a separate and later date than the original interpretation, Fulkerson says. Carriers won't pay for the same code billed by two different physicians on the same day, but they will pay if the radiologist bills for the DEXA first and the endocrinologist bills for the professional component several days later.
Don't append -26 when: If a radiologist performs the DEXA scan and submits the uninterpreted results to your endocrinologist, he has performed only the exam's technical component. Many times, however, the radiologist will also perform the professional component -- reading and interpreting the results, says Jordan B. Renner, MD, professor of radiology and allied health sciences at University of North Carolina School of Medicine in Chapel Hill. In this case, the radiologist will bill for the entire service (both technical and professional components), and your endocrinologist will be unable to bill for any further interpretation he does that day. If your practice has a DEXA unit in-office, however, your endocrinologist is the one who should bill the global DEXA code.

- Published on 2004-07-21