Wiki modifer 26 on lab claims

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Ruthannpardo

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Is there any reason that there should be a modifier placed on any lab claim other than pathology? I am confused. The lab (EX; CBC; 85027 or clotting factor; 85246) is read by the physician treating the patient. So there should only be one bill for 85027 or 85246 (no 26 modifier) correct??
 
Ruthannpardo said:
Is there any reason that there should be a modifier placed on any lab claim other than pathology? I am confused. The lab (EX; CBC; 85027 or clotting factor; 85246) is read by the physician treating the patient. So there should only be one bill for 85027 or 85246 (no 26 modifier) correct??
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Modifier 26 is only used for CPT codes that can have a professional/technical split.

85027 and 85246 (and most labs) do not have a PC/TC split.

Who is running the actual test? The supplies and equipment used to run the test - who owns it? That’s who generally bills the lab CPT.

When physicians review lab results, normally that’s a component of the E/M service.

Is your physician actually running the test or just reviewing the results run by the lab?
 
Thank you, True Blue! Yes, reviewing the test. Of course, that makes sense. Can you direct me to where i would find the correct codes with the professional/technical split? Thanks again.
 
Ruthannpardo said:
Thank you, True Blue! Yes, reviewing the test. Of course, that makes sense. Can you direct me to where i would find the correct codes with the professional/technical split? Thanks again.
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The Medicare physician fee schedule will show the codes that can be billed with a professional component. You can search for a range of codes in the 80000-89999 range if you want to see which codes might have a professional component. (In that code range, you'll see that it is mostly pathology.)

Here is the CMS physician fee schedule lookup: https://www.cms.gov/medicare/physician-fee-schedule/search

Most lab codes are on the Clinical Lab Fee schedule and not in the Physician Fee Schedule Look Up. If a lab code is on the Clinical Lab Fee Schedule, it does not have a technical/professional component. Here's where you can find the CMS Clinical Lab Fee Schedule: https://www.cms.gov/Medicare/Medica...eSched/Clinical-Laboratory-Fee-Schedule-Files

Your physician doesn't get to bill a lab code just for looking at the lab results. Reviewing lab results is part of the Medical Decision Making for an E/M service. If your physician is giving you push back on that, you can show them an E/M Audit sheet demonstrating that ordering and reviewing of results are part of the overall MDM for a visit: https://www.aapc.com/codes/em-calculator-2023/mdm
 
Thank you so much for your support. You have provided me with the right site to support the above. What a huge help and a wonderful Christmas present. Thanks again, I am now armed ;)
 
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