Practice Management Alert

If the equipment’s not yours, you might need this modifier.

Medical practices often need to perform services using another facility’s equipment. When this occurs, the practice must be able to decide whether to include modifier 26 (Professional component) on the claim.

In most cases where your provider performs a service with equipment your practice doesn’t own, you’ll need to include modifier 26 to show that you are only coding for your physician’s service.

Result: When you report modifier 26, the payer “reduces payment to just the physician’s work, not the cost of the equipment,” explains Kelly D. Dennis, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. While using modifier 26 correctly will reduce your pay, it’ll also mean you’ve coded correctly — which should be the main concern of every medical practice.

Check out this advice on when you might need modifier 26 to complete your claim.

‘Professional Services’ Mean 26 Opportunity

Coders employ modifier 26 most commonly in “office or outpatient facilities when the equipment is the property of the clinic or facility, and not [your] physician,” explains Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, medical coding director at Acusis in Pittsburgh, Pa.

Often, a CPT^® code’s relative value units (RVUs) are broken down into a technical component and a professional component; you’ll append modifier 26 when your physician only provides the professional component of one of these codes, confirms Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J. 

If you don’t use modifier 26 when appropriate, you’ll open your practice up to accusations of overcoding and all sorts of potential red tape.

Check These Modifier 26 Hotspots

There is no definitive list of the places of services a modifier 26 claim might occur. The following locations are far more likely to see many modifier 26 claims, confirms Yvonne Bouvier, CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind.:

• hospital operating rooms (ORs),
• hospital emergency departments (EDs),
• laboratories,
• hospices and
• radiology clinics.

One common modifier 26 scenario is x-rays. Let’s say your physician performs a two-view thoracic spine x-ray. Unless she owns the x-ray equipment, you’d report 72070 (Radiologic examination, spine; thoracic, 2 views) with modifier 26 appended.

Lab Tests Are Often 26-Eligible

While many modifier 26 encounters occur outside of your practice walls, there is no site of service requirement to use the modifier. And there are also codes, mostly in the radiology section and medicine testing sections of CPT^®, that are divided into professional and technical components. Some of these codes include:

• 73040, Radiologic examination, shoulder arthrography, radiological supervision and interpretation
• 77053, Mammary ductogram or galactogram, single duct, radiological supervision and interpretation
• 93880, Duplex scan of extracranial arteries; complete bilateral study
• 91020, Gastric motility (manometric) studies
• 91010, Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report.

Example: The physician performs a complete duplex scan of a patient’s extracranial arteries. You don’t need a modifier if the physician performs the procedure in the office; you’d report 93880.

If this scan was performed in a hospital, however, you’ll need to report 93880 with modifier 26 appended. 

Best bet: When you’re coding for one of these services, have modifier 26 at the ready in case you need to use it.