Inpatient Facility Coding & Compliance Alert

Question: When should I use modifier 26?

Alabama Subscriber

Answer: CPT^® designed modifier 26 (Professional component) for use when reporting professional services in which the code is a combination of professional and technical components. When your provider only performs the professional component of the service, modifier 26 tells the payer that you are only coding for that portion of the service and thus payment will be made for the professional services.

You should also use modifier 26 when the provider performs a procedure with both a technical and professional component in an off-site facility, in other words, in a place of service other than the office. If the provider performs a procedure in a facility owned by another party, you must use modifier 26 on your code[s]; the facility should report the same code[s] with modifier TC (Technical component) appended.

Failure to use modifier 26 when the situation calls for it means the payer will consider your practice the global provider of the service, and the payer will reimburse you the full fee for both the professional and technical components.

Remember: This coding could result in payers requesting a refund for payment as the result of incorrect coding. This practice could also put you on a payer’s radar for future claim scrutiny.