Gastroenterology Coding Alert

Who owns the equipment is only part of the story for proper coding

Using modifier 26 in the facility setting is not always straightforward. Here are the facts you need to make sure your physician gets the payments she deserves, every time.
 
Generally, if a physician conducts diagnostic tests or other services using equipment she doesn't own, you should append modifier 26 (Professional component) to indicate that she provided only the physician component (the administration or interpretation) of the service. Our coding experts weigh in on how to use this modifier correctly every time.

Separate the Technical and Professional

If your physician provides both components of the service, he may report the appropriate CPT code with   no modifiers.

But, -when the physician component is reported separately,- CPT specifies, -the service may be identified by adding modifier -26- to the usual procedure number.- In the latter case, the facility providing the equipment may claim the -technical component- of the service (the cost of equipment, supplies, technician salaries, etc.) by reporting the appropriate CPT code with modifier TC (Technical component) appended.

Explanation: CPT's Appendix A (-Modifiers-) explains that some procedures are a combination of a technical component and a physician (or professional) component. If the far left-hand column of the CMS Physician Fee Schedule database lists separate values for the code with modifiers 26 and TC, modifier 26 is appropriate if the physician provides only the service's professional component.

Tip: The Physician Fee Schedule, updated annually, is available as a free download at the CMS Web site http://cms.hhs.gov/physicians/pfs/.

Example: The fee schedule lists values for both professional and technical components (0.44 and 3.98 relative value units, or RVUs, respectively) for motility study 91010 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study). In other words, the full value of the code (4.42 RVUs) includes performance of the study, interpretation and report, as well as a fee for equipment, staff, etc.

Therefore, if the GI performs the test using equipment owned by a hospital or other facility and provides interpretation only, he must append modifier 26 to 91010. The facility will bill separately, appending modifier TC to 91010 to receive compensation for use of its equipment.

If the gastroenterologist fails to append modifier 26 and the facility nonetheless bills with modifier TC, the technical portion of the service will have been double-billed, which could lead to accusations of fraud or a demand for repayment, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

Medicine, Radiology Codes Call for 26

In a gastroenterology practice, the codes you-ll most commonly apply that contain a professional (modifier 26) and technical (modifier TC) component appear in the -Medicine- portion of CPT. Specifically, gastro testing codes 91000-91065, 91110-91122 and 91132-91299 all contain both technical and professional components.
 
Other procedures you might bill in a gastroenterology practice that include both professional and technical components are fluoroscopic guidance services, such as 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation) and others.

Ownership Isn't Everything

Determining if modifier 26 is appropriate is not always as simple as asking, -Does the physician own the equipment?- When billing Medicare, for instance, physicians providing services in a hospital or facility setting cannot claim the technical portion of a procedure regardless of whether they own the equipment, says Neil Busis, MD, clinical associate professor at the University of Pittsburgh School of Medicine.

For instance, if the gastroenterologist orders 24-hour pH testing (91034, Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording,  analysis and interpretation) on a hospital inpatient using his own machine, he must append modifier 26.

Here's why: Under the diagnosis-related group (DRG), the hospital receives payment for the technical component of Medicare inpatient services. In fact, for Medicare, the only time that you don't use modifier 26 is for testing of outpatients using your own equipment.

Negotiate With the Facility for Fee

A physician can still receive reimbursement for inpatient testing. Although the physician cannot bill the carrier for the technical component under the DRG system, he may either bill the facility or establish a separate contract with it to receive the appropriate reimbursement, Busis says. This would apply in cases when the physician:

1. owns the equipment
2. employs the technician who performs the test, or
3. personally performs the test.

Even if the hospital owns the equipment, if either 2 or 3 of the above is true, the physician can recoup some payment, but this will require negotiation with the facility for which he is providing the tests.