Neurology & Pain Management Coding Alert

Reporting modifiers 26 (Professional component) and TC (Technical component) for EEGs may seem a breeze, but if you forget to apply modifier 26 on your claim when your neurologist renders the service in a facility setting, you could be setting yourself up for serious double-billing accusations.

The issue: Often, coders "don't split up the technical and professional components," says Angela Cook, patient accounts manager with a physician institute in Lecanto, Fla.

Don't fall into this trap: Brush up on your professional and technical component modifier skills, and learn what to do when your neurology practice purchases the technical service.

Certain CPT codes, including most diagnostic studies, such as those for EEG code 95822 (Electroencephalogram [EEG]; recording in coma or sleep only), are made up of two components: the technical component (modifier TC) and the professional component (modifier 26).

Keep track: "TC is for the entity that owns the equipment," says Peggy Stilley, CPC, office manager for an Oklahoma University-based private physician practice in Tulsa. "The 26 modifier is for the professional interpretation."

Example: If your neurologist performs a sleeping or comatose EEG with a facility's equipment, you should use 95822 and append modifier 26 to reflect that he interpreted the findings and wrote the report.

Check it out: You should not use modifier 26 with procedures that are either 100 percent technical or 100 percent professional. You should use these modifiers only on procedures having both components.

Warning: If your neurologist fails to append modifier 26 but the facility bills with modifier TC, the technical portion of the service will have been double-billed.

This can lead to accusations of fraud or a demand for repayment, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, RCC, CodeRyte coding analyst and coding review teacher.

Safeguard: Medicare will not pay a physician for the technical component of services provided in a facility setting, such as inpatient (POS 21) or an outpatient hospital (POS 22) setting. In many cases, the Medicare carrier will deny processing and the physician will need to resubmit a corrected bill with modifier 26 appended.

The facility owning the EEG equipment in the above example would report the EEG code 95822 using modifier TC for its portion of the test. Using modifier TC here indicates to the payer that the facility supplied only the technical component, not the professional interpretation, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.

If your neurologist performs both the technical and professional components in an office setting (POS 11), he should submit a CMS-1500 form with the CPT code and no modifier to indicate he provided the global procedure, Hammer says.

For example, according to Regence BlueCross BlueShield of Oregon, "A -complete- procedure [that is, professional plus technical component] billed with no modifier attached to the procedure code, is only eligible for reporting and reimbursement when that provider owns the equipment and is also providing the professional component."

But suppose that your neurologist does not have the capability to perform an EEG or other diagnostic test in his office. Instead, he contracts with another physician, medical group, or supplier to perform the technical component for him.

A provider that does not own the diagnostic equipment or employ the necessary staff to perform the study may purchase the technical component from another supplier and potentially receive reimbursement for both components, Hammer says.

The Medicare Claims Processing Manual 100-04, Chapter 1, 30.2.9, Payment to Physician for Purchased Diagnostic Tests -- Claims Submitted to Carriers, states, "A physician or medical group may submit the claim and (if assignment is accepted) receive the Part B payment, for the technical component of diagnostic tests which the physician or group purchases from an independent physician, medical group, or supplier" (http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf).

Here's the catch: In order to purchase a diagnostic test, the purchaser must perform the interpretation -- and the physician or other supplier that furnished the technical component must be enrolled in the Medicare program. In addition, for payment, the physician who purchases a test from an outside source must identify the supplier, the supplier's provider number, and the amount that the supplier charged.

According to Medicare, you should not submit a global code on your claim when your practice purchases one component of the service. Instead, bill it as split-billed or separate line items, with one line using modifier 26 for your neurologist's interpretation; bill the second line with the TC indicating a purchased technical component, such as 95822-26, 95822-TC.

Potential problem 1: Always be sure to indicate when you purchased the technical component. If you do not indicate that you purchased it, you have a potential false claim.

Potential problem 2: If you purchase the technical component, Medicare states you are not allowed to mark up the price. What you have to put down as the charge is the allowable fee schedule amount or the actual amount you paid -- whichever is less.

Prior to reporting for purchased test components, make sure to consult with your attorney about other regulatory concerns before changing any practices.