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 [...]