Oncology & Hematology Coding Alert

Hint: These modifiers can’t separate every service.

When your oncologist performs certain services, such as interpreting an image, you might automatically reach for modifier 26 (Professional component). However, the use of this modifier is more complicated than you might think.

Below are five tips to assist you in determining when to appropriately apply modifiers 26 and TC (Technical component) to oncology services, and when you should refrain.

1. Differentiate Between ‘Technical’ and ‘Professional’ Component Codes

Many services paid through the Medicare Physician Fee Schedule (MPFS) describe a global service that includes both technical and professional components of the code. However, you should only bill the entire global service when a provider owns the equipment, personally performs the service and, in the case of testing or imaging, personally interprets the results of the test or image.

In this case, you can append modifiers 26 or TC to inform insurers that you provider did not perform both parts of the service but instead only performed the professional interpretation (26) or the performance of the test itself (TC).

Tip: You can learn how to pinpoint codes with separate technical and professional components for Medicare payers in Tip 4 below.

2. Break Out Global Components

The most straightforward uses of modifiers 26 and TC occur when your aim is to report the component of a global code the provider personally performed when a separate entity performed the other component.

Modifier TC is a HCPCS Level II modifier that covers the provision of all equipment, supplies, personnel, and costs related to performing the procedure. For instance, if your practice owns X-ray equipment and provides images for another provider who is not associated with your practice, you should bill the code with modifier TC. When you report the technical component, your practice will get reimbursed only for the equipment, supplies, and staff cost involved in producing the imaging.

Modifier 26 is a CPT^® modifier that describes a physician’s professional services in interpreting the image or test when a separate entity performed the technical portion of the service. For instance, in the prior example, the oncologist who interprets an X-ray image taken at another facility would bill the appropriate radiology image CPT^® code with modifier 26.

In summary, the technical component includes the supplies, equipment, and technician labor involved in performing the procedure (i.e., generating images the physician receives for interpretation and report), while the professional component generally represents the physician’s review, evaluation, and interpretation of the diagnostic image.

This billing and code reporting concept can also be applied to some pathology and medicine diagnostic services when only the global code exists in the CPT^® code book and accepts modifiers TC and 26.

3. Understand Payment Differences

If you’re billing for both the technical and professional components of a particular code, you’ll collect the global fee reflected in the MPFS database. The MPFS database will also outline what you would collect if reporting the same code with modifier 26 or modifier TC appended.

Example: Your oncologist bills Medicare for a complex brachytherapy plan using 77318 (Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)). If the entire service was performed in-house, it would be inappropriate to append a modifier to reflect a professional and technical split; however, if the oncologist used another facility’s equipment, you would append modifier 26 to the code, and the facility would bill the same code separately using modifier TC.

Tip: For facility billing, some payers, especially Medicare, assume the modifier TC when reporting diagnostics on a UB-04 claim. These claim types report only the facility resources and not a physician’s professional services for the interpretation and report.

Once you append the TC or 26 modifier, payment amounts will differ. The following are non-facility fees from the 2024 MPFS and are not adjusted for geographic pay differences:

• 77318 with no modifiers: $458.70
• -26: $150.46
• 77318-TC: $308.24

You’ll note that the payment amounts for modifiers 26 and TC, when added together, total the amount allotted for the global fee. This provides you with a breakdown of where CMS sees most of the work happening (in the case of 77318, that would be the technical component).

4. Know When Codes Are Professional or Technical Only

Some oncology codes may be technical or professional only codes. Appropriate assignment will rely on the code description.

Professional-only services generally include words such as “interpretation and report” or “consultation” in their descriptors: for example, 88141 (Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician) or 85097 (Bone marrow, smear interpretation). Code 88184 (Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker), however, is a technical-only code, which is clearly outlined in the code descriptor.

In other words, you should never append modifiers 26 or TC to these code types. So, it is important to read the descriptions of the codes to know when modifiers are appropriate.

Don’t forget the PC/TC indicator: If you are ever in doubt which codes take a 26 or TC modifier, you should check the code’s indicator in the PC/TC column of the MPFS, found at https://www.cms.gov/medicare/physician-fee-schedule/search.