ED Coding and Reimbursement Alert

Do you know when to use professional component modifier?

There are times when your physician will provide only a portion of a service represented by a particular CPT^® code.

When this occurs, you might need help from a couple of modifiers in order to untangle your ED provider’s deserved reimbursement from the other relative value units (RVUs) of the CPT^® code.

Enter 26, 54: Modifiers 26 (Professional component) and 54 (Surgical care only) are frequently used in these situations to show the payer that you are only coding for the portion of the service your surgeon performs. Check out our expert advice on best use of modifiers 26 and 54.

Report 26 for Professional Component Only

Modifier 26 is a modifier ED coders need to know how to use, considering the ED setting. Modifier 26 “is used mostly in office or outpatient facilities when the equipment is the property of the clinic or facility and not the physician,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med Group in Pittsburgh.

According to Kelly Dennis, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida, “some procedures are a combination of both a physician component and a technical component. Using modifier 26 identifies the physician’s component. When a 26 modifier is reported, it reduces payment to just the physicians work, not the cost of the equipment.”

“This modifier is appended when a service code includes the technical component as well as the professional component, and the only component performed is the professional component,” explains Hauptman.

This splitting of the service into professional and technical components happens often when your provider uses someone else’s facility/equipment. “It is used mostly in office or other outpatient facilities when the equipment is the property of the clinic or facility and not the physicians,” explains Hauptman. For example, if a patient has an X-ray in a hospital, “the facility would bill for the technical component of the test and the physician who reads and interprets the test, creating a report, will bill for the professional component; thus, the 26 modifier is needed to demonstrate the split.

Example: The ED physician decides to send the patient down the hall for an X-ray of the thoracic spine (two views). Once that is performed, your doctor will interpret it and write a report. They don’t own the equipment as it is part of the hospital’s equipment, nor do they employee the radiology tech, so you can’t bill for the technical component.

For this X-ray, you’d report 72070 (Radiologic examination, spine; thoracic, 2 views) with modifier 26 appended.

“The technical component of actually capturing the views was done by the facility; and thus, they will bill that portion with a TC [Technical component] modifier. The physician, on the other hand, will use the 26 modifier to illustrate their involvement in the service,” according to Hauptman.

Follow This Advice for 26 Success

Using modifier 26 inappropriately could lead to some issues with payers. “You may get paid in full for a service you did not totally perform; or you may not get paid at all,” Hauptman warns.

Also, the Office of Inspector General (OIG) is an issue, “as it watches the professional services, and the 26 modifier, very carefully,” she continues.

To ensure proper modifier 26 use, Hauptman encourages coders to follow these basic guidelines:

• “Understand what is included in the description of the code — some codes are for only the profes­sional component and you wouldn’t need the 26 modifier; for example 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).
• “Understand exactly what your physician did and read the documentation associated with the service.
• “Know what equipment is owned by your practice and what is owned by the various facilities where your doctor sees patients.
• “Understand the relationship your physician has with the facility, as they might bill the global fee and pay the physician based on a contract.”

Surgical Component Only? Use 54

Another instance where you would be coding only for a portion of the service involves surgeries, and modifier 54. Use 54 “when the physician provides only the surgical procedure — pre-op and intraoperative care — and another physician provides post-op care,” explains Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, New Jersey.

Explanation: Of note, starting in 2011, the global period for simple laceration repairs changed from 10 days to zero days, meaning the follow-up visits/suture removal are no longer included in the initial service. If the patient does return to the ED for the follow-up care, report the appropriate E/M service. (Note: The global period for intermediate and complex laceration repairs did not change; the change was only for simple repairs.)

In general, if follow-up care elsewhere was a given for a major procedure, then you would append modifier 54 to the surgical code. According to the Medicare Carrier’s Manual, Section 40.2.3: “[Other] Physicians who provide follow-up services for minor procedures performed in the ED bill the appropriate office visit code. The physician who performs the ED service bills for the surgical procedure without a modifier.”

Remember: You should append modifier 54 to the procedure code when it is clear your provider will be providing surgical care only. The provider should advise the patient to obtain postoperative care elsewhere, perhaps with a referral.

Example: A patient who is in the area water skiing suffers a right ulnar shaft fracture. The physician performs open reduction and internal fixation of the shaft. Notes indicate that the patient will return home before they need postoperative care, and a surgeon local to the patient will provide post-op care. There is documentation to attest to the fact that another surgeon will handle post-op care in the notes.

On this claim, you’ll report 25545 (Open treatment of ulnar shaft fracture, includes internal fixation, when performed) with modifiers 54 and RT (Right side) appended.