Radiology Coding Alert

Question: I have heard conflicting advice about whether modifier 26 is necessary when we report wall motion and ejection fraction add-on codes. Are there certain instances when we should use this modifier?

Alabama Subscriber

Answer: When your radiologist interprets wall motion (+78478, Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure]) and ejection fraction (+78480, Myocardial perfusion study with ejection fraction [list separately in addition to code for primary procedure]) studies but your practice did not furnish the technical portions of the service, you should append modifier 26 (Professional component) to the appropriate add-on code.

The myocardial perfusion test's technical portion, which the facility will report, includes payment for the technical staff who administered the wall motion study, utilities and supplies. Physicians typically bill the professional component only in hospital settings or when an outside facility administered a test and someone requests their interpretation. Modifier 26 tells the insurer that you are billing for only the radiologist's interpretation.

How you know: Both 78478 and 78480 have a PC/TC (professional component/technical component) indicator of "1" in the Medicare physician fee schedule. That 1 means these are diagnostic tests or radiology services, according to Medicare Claims Processing Manual, chapter 23 (www.cms.hhs.gov/manuals/downloads/clm104c23.pdf).

"Modifiers 26 and TC can be used with these codes. The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense. The total RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only. The total RVUs for codes reported without a modifier equals the sum of RVUs for both the professional and technical component," the manual explains.