Wiki Modifier 26 and Laboratory codes

[Ruthannpardo]

When is it appropriate to bill for the professional component of a laboratory procedure when the patient is in a facility? Or is it appropriate? Or, are there some CPT's that modifier 26 applies (ex; surgical pathology CPT 88302) and some that don't? For example 85610 prothrombin time, isn't that 'read' by a machine and then the physician that sees the patient identifies what the value means. Would there be a professional component on 85610 while the patient is in the hospital?

 

[sls314]

When is it appropriate to bill for the professional component of a laboratory procedure when the patient is in a facility? Or is it appropriate? Or, are there some CPT's that modifier 26 applies (ex; surgical pathology CPT 88302) and some that don't? For example 85610 prothrombin time, isn't that 'read' by a machine and then the physician that sees the patient identifies what the value means. Would there be a professional component on 85610 while the patient is in the hospital?

It's a relatively small number of codes in the lab/pathology range that can be split into a professional & technical component. For the codes that do have a TC/26 split, the pathologist would typically be the one billing the professional component.

Reviewing lab results is typically considered part of the E/M visit.

 

[Ruthannpardo]

It's a relatively small number of codes in the lab/pathology range that can be split into a professional & technical component. For the codes that do have a TC/26 split, the pathologist would typically be the one billing the professional component.

Reviewing lab results is typically considered part of the E/M visit.

Thank you Susan! I don't see any reference in CPT regarding which ones CAN/SHOULD have both the technical and the professional component. Can you direct me somewhere?

 

[sls314]

Thank you Susan! I don't see any reference in CPT regarding which ones CAN/SHOULD have both the technical and the professional component. Can you direct me somewhere?

If you use an online encoder program:
Your encoder software may show what modifiers can be billed with each CPT/HCPC code as well. I know that EncoderPro and FindACode both have a modifier crosswalk, I would guess Codify does too.

If you don't use an encoder program or just want to know another way to research it:

I usually use the CMS Physician Fee Schedule as a reference to show which items can be billed with a 26/TC split. Only the codes that have an entry with a 26 modifier can be billed as a professional component.

You can search for the range of lab/path codes and export as a CSV: https://www.cms.gov/medicare/physician-fee-schedule/search

Note - you won't see all of the lab codes in the CMS Physician Fee Schedule. CMS pays most labs based on the Clinical Lab Fee Schedule. None of the codes on the Clinical Lab fee schedule have a professional component, but if you want to see the Clinical Lab Fee Schedule for other purposes you can find it here: https://www.cms.gov/Medicare/Medica...eSched/Clinical-Laboratory-Fee-Schedule-Files

 

[Ruthannpardo]

Thank you SO much! I appreciate you.