Otolaryngology Coding Alert

Question: Sometimes our provider will perform a computerized tomography (CT) maxillofacial without contrast in-house, but the scan will be sent to an outside source for interpretation. Other times, the provider will refer the patient to the radiologist on call, who then performs both the scan and interpretation. Which modifier should our provider bill out with in each example?

Washington Subscriber

Answer: In the second scenario, your provider will not bill out for the procedure at all since an outside physician performs and reads the procedure elsewhere. The outside diagnostic facility will bill for their services. When the patient receives imaging in-house, the provider is allowed to bill out without any modifier, assuming that the provider owns the equipment and performs the interpretation.

In the first example, the physician can apply the TC (Technical Component) modifier to code 70486 (Computed tomography, maxillofacial area; without contrast material) on one claim since they own the equipment but did not interpret the report. The interpreting provider will bill out using modifier 26 (Professional Component Only [separate from technical component]) with code 70486, explaining that the provider only interpreted the report, but did not own the equipment. If the TC and 26 modifiers are split between two parties, the TC component can expect to receive 60 percent reimbursement and the professional component will receive the remaining 40 percent reimbursement.