SEPARATE Professional & Technical Components with 26 and TC
By G. John Verhovshek, MA, CPC
Certain services defined within CPT® contain separate professional and technical components. That is, the complete service, as reported by a single CPT® code, includes reimbursement for the physician’s work of the service—generally physician interpretation and report, or a diagnostic test’s administration—and separate payment for necessary equipment usage and ancillary costs.
As a rule, codes with both a professional and technical component describe equipment-intensive diagnostic services, including many services found in the radiology (70000 series) and medicine (90281-99607) sections of the CPT® manual. When reporting these codes, you may separate a service’s professional and technical components from one another with proper application of modifiers 26 Professional component and TC Technical component.
Identifying Qualifying Codes
The CPT® manual does not identify specifically codes with separate professional and technical components. You may identify them readily, however: The Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (PFS) Relative Value File lists such codes on three separate lines, each with a different relative value unit (RVU) total. The first line describes the global service; the second line describes the service’s technical component (as indicated by “TC” in column B of the fee schedule), and; the third line describes the service’s professional component (as indicated by “26” in column B of the fee schedule).
Resource tip: You may download the CMS National PFS Relative Value File from the CMS Web site at: www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4. Be sure to select the most recent file.
Applying Modifiers 26 and TC
Most often, you will append modifier 26 when the physician does not own the equipment necessary to provide the service, such as when the physician provides the interpretation and report for an X-ray taken in a facility setting.
When billing Medicare, physicians providing services in a facility setting cannot claim the procedure’s technical portion regardless of whether they own the equipment. For instance, if a neurologist performs electromyography (EMG) (such as 95860 Needle electromyography; one extremity with or without related paraspinal areas) for a Medicare inpatient using his own machine, he must append modifier 26. The hospital receives the payment for the technical component of any service provided in the facility as part of the diagnosis-related group (DRG) payment for Medicare inpatients. This is true even if the physician performs the service for a hospital patient in his or her office.
If, however, the physician provides the complete outpatient service in his office, using his own equipment, you may report the appropriate CPT® code without a modifier appended to receive reimbursement for the complete service.
For example, per the 2009 PFS Relative Value file, the neurologist reporting 95860 to Medicare in the facility setting recovers 0.96 RVUs for the professional portion of the service only. If the neurologist provides the same service for an outpatient in his own office, using his own equipment, he reports 95860 without a modifier, and receives a total of 2.16 RVUs for the complete service.
A physician practice may report a service with modifier TC only, but it would happen rarely. For example, suppose that several ophthalmology practices lease space within the same office complex. Practice A has had equipment difficulties, and arranges with Practice B to provide the technical portion of, for instance, visual field testing (92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination [eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) for Practice A’s patients. Practice B provides the printouts for Practice A, and Practice A performs the interpretation and report. In this case, Practice A would report 92081-26, and Practice B would report 92081-TC.
G. John Verhovshek, MA, CPC, is AAPC’s director of clinical coding communications.