Neurosurgery Coding Alert

Question: What are the guidelines for reporting professional services?

South Dakota Subscriber

Answer: When a physician conducts diagnostic tests or other services using equipment supplied by a hospital or other facility, he or she may have to append modifier -26 (Professional component) to the appropriate CPT code to indicate that only the physician component (e.g., administration or interpretation) of the service was provided.
 
Appendix A of CPT explains that some procedures are a combination of a physician component and a technical component. "When the physician component is reported separately," CPT further specifies, "the service may be identified by adding the modifier '-26' to the usual procedure number" or by attaching the five-digit modifier code 09926.
 
The easiest way to determine if a particular CPT code contains both a professional and technical component is to consult the Physician Fee Schedule. Check the far left-hand column, which lists each individual CPT code. If the Fee Schedule lists separate values for the code with modifiers -26 and -TC (Technical component), then modifier -26 is appropriate for that code if only the professional component of the service is provided (the physician does not own the equipment that he or she uses to provide the service). Typically, the technical component (-TC) reflects the practice expense and malpractice RVUs, while the professional (-26) component reflects the work RVUs only.
 
Note: An updated fee schedule is announced yearly in the Federal Register and is available as a free download on the CMS Web site (www.hcfa.gov).
 
For example, in some circumstances the surgeon may use fluoroscopic guidance to ensure access to the correct spinal level. The Fee Schedule reveals that 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) and 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) include both professional and technical components. In other words, the full value of the codes includes performance of the study, interpretation and report. This means that modifier -26 is appropriately appended to 76005 if the surgeon performs the test using equipment owned by a hospital or other facility and provides interpretation only. The facility will bill separately, appending modifier -TC to 76005 to receive compensation for use of its equipment. If the surgeon 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.
 
For third-party payers, modifier -26 should be appended only if the physician does not own the equipment that he or she uses to provide the service, or reimbursement will be unnecessarily decreased (e.g., the physician should not append modifier -26 when performing a diagnostic test in his or her office using his or her own equipment). When billing Medicare, however, physicians can't directly bill for the technical component of a procedure even when they use their own equipment in the hospital. The hospital diagnostic related groups (DRGs), by law, cover the technical component of Medicare services for inpatients. For Medicare, the physician must bill the institution by a separate (fair-market value) agreement if the physician is to to recover the reimbursement of the technical component for these studies. This is an unlikely situation for surgeons, who perform most of their surgical services in the hospital setting using hospital equipment.