Ophthalmology and Optometry Coding Alert

Master your professional component claims with these quick tips.

Modifiers 26 and TC go together like peanut butter and jelly — most of the time. But if you don’t have a handle on when you should and shouldn’t append modifier 26 (Professional component) to your ophthalmologist’s claims, you could find your claims denied or delayed. Consider the following four Dos and Don’ts to perfect your modifier 26 coding knowledge.

DO: If your provider performed only the interpretation and report for a procedure or service, such as a visual field test, you should bill the service by attaching modifier 26 to the CPT® code. The technologist that performed the VF (the technical portion of the service) will usually submit the same CPT® code with modifier TC (Technical component) attached. In other words, the ophthalmologist bills for his reading and reporting of the VF, while the facility bills for the equipment, room, and technician.

Example: A technician in your office performs a visual field ordered by a doctor outside the practice. The patient is not being seen by any doctor in the practice, and the visual field is sent back to the ordering doctor for interpretation. Report only the technical component of the visual field test, 92081 (Visual field examination, unilateral or bilateral, with interpretation and report; limited examination ... ), 92082 ( ... intermediate examination [e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33]) or 92083 (...extended examination [e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2 or 30/60-2]).

Append modifier TC (Technical component) to the code to report your work. The ordering doctor who will receive the test results and provide an interpretation and report should report his work by appending modifier 26 (Professional component) to the code.

Tip: Technical component charges are institutional charges, made by a person or facility which actually owns the equipment, and are not billed separately by physicians.

DON’T: You should not use modifier 26 with procedures that are either 100 percent technical or 100 percent professional. You should use it only on procedures having both components.

Warning: If the physician 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 from your carrier.

Safeguard: Medicare will not typically pay a physician for the technical component of services provided in a facility setting. In other words, if your claim lists a place of service (POS) as an outpatient hospital (POS 22), this will prevent double-billing from happening.

DO: Check the rules when treating hospital inpatients, even if you’re using your personal equipment. When billing Medicare, for instance, physicians providing services in a hospital or facility setting cannot typically claim the technical portion of a procedure regardless of whether they own the equipment.

Here’s why: Under the diagnosis-related group (DRG), the hospital receives payment for the technical component of Medicare inpatient services. 

A physician can still receive reimbursement for inpatient testing. Although the physician cannot bill the carrier for the technical component under the DRG system, he may either bill the facility or establish a separate contract with it to receive the appropriate reimbursement when necessary. This could apply in cases when the physician:

1. owns the equipment
2. employs the technician who performs the test, or
3. personally performs the test.

DON’T: You must avoid using modifier 26 for a reinterpretation of another physician’s diagnostic test. Suppose the patient gets a fundus photograph (92250, Fundus photography with interpretation and report) elsewhere where it’s interpreted by an ophthalmologist, then he brings the raw data test findings (not a report) back to you for an additional interpretation. In this case, you should not bill for interpretation because the other ophthalmologist has already reported it. You should count your doctor’s re-read toward the medical decision-making portion of the E/M for that visit.