Oncology & Hematology Coding Alert

Many oncology practices assume that all procedures that office-based physicians order to be performed in a hospital outpatient facility have both professional and technical components.
 
The truth is that oncology-related procedures vary as to whether they have one or both components. For example, a special radiation physics consultation (77370) has only a technical component, treatment planning codes (77261-77263) are professional only, and simulations (77280-77295) comprise both. You can append modifier -26 (professional component) to these dual-component procedures if the oncologist can document participation and/or involvement in the procedure, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a Dallas, Ga.-based coding consulting firm with a number of radiation oncology clients.  
 
Hospital medical and radiation oncologists normally interpret test results rather than administer them. In essence, the hospital is paid for the technical component while the oncology practice is paid for analyzing test results and films (professional component). The technical component includes elements such as the room where the tests were done, the equipment used, supplies and the technician's salary -- all paid by the hospital. The professional component, on the other hand, is the skill and expertise the physician provides to interpret the test results.
 
If the hospital performs both the procedure and interpretation of test results, only the hospital should bill for the procedure's technical and professional component, says Catherine Brink, CPC, CMM, president of Healthcare Resource Management Inc. in Spring Lake, N.J.

 
Physicians order diagnostic mammograms for patients with signs and symptoms of breast disease, a personal history of breast cancer, biopsy-proven benign breast disease, or abnormal findings on a screening mammogram. Diagnostic tests are unlike mammography screenings, which are preventive and normally performed without any specific symptoms of breast disease.
 
Oncology practices that lack the necessary equipment and staff must rely on a nearby hospital for these services. But, if the practice interprets the results, dictates the report and bills for the professional portions, you must attach modifier -26 to either 76090 (mammography; unilateral) or 76091 (mammography; bilateral). Failure to separate the technical and professional components can lead to claim denial: Because the service was delivered in a hospital, Medicare might determine that only the hospital is entitled to bill for the service because no professional component was established.
 
Sometimes hospitals that perform diagnostic tests for outside practices do so with the understanding that hospital medical staff will interpret the results and provide a report to the practice. But the oncologist might review the results as well to compare findings. Practices must be sure that the facility does not interpret test results and bill for them, Brink warns.
 
If the facility provides an interpretation, it is entitled to reimbursement for the technical component, and the hospital-affiliated physician bills for the professional component with modifier -26 attached. In this case, the oncologist who ordered the procedure cannot bill for any portion of the procedure. "There is no such thing as two interpretations," Brink says. "If a physician interprets the results to compare his findings to the hospital's report, that is considered part of medical decision-making, which is covered under E/M services."