PC and 26 Confusion Causes Delayed Payment

Physicians should expect claims processing delays when submitting line items with modifier PA Surgery wrong body part, PB Surgery wrong patient, or PC Wrong surgery on patient. Modifier PC, in particular, has created so much confusion among providers, according to the Centers for Medicare & Medicaid Services (CMS), the agency has instructed contractors to suspend, review, and develop all claim lines containing modifier PC , PB, or PA.

Effective Jan. 15, 2009, hospital outpatient departments (HOPDs), ambulatory surgical centers (ASCs), and practioners are required to append the appropriate modifier—PA, PB, or PCto all lines related to an erroneous surgery.

Ambulatory Surgical Center CASCC

The problem is, some providers are incorrectly using the PC modifier to report the professional component of a service.

The PC modifier was at one time used to report the professional component of a service when someone other than the physician performed the technical component, which continues to be reported with modifier TC Technical component (hence the confusion). Current guidelines, however, stipulate modifier 26 should be used to report the professional component.

Modifier 26 designates a service as “interpretation only” and is most commonly submitted with diagnostic tests, inlcuding radiological procedures. Part B Medicare Administrative Contractor (MAC) Palmetto GBA refers you to the Medicare Physician Fee Schedule database (MPFSDB) to determine if modifier 26 is applicable to a particular procedure code.

For proper uses of modifiers PA, PB, and PC, read MLN Matters article MM6405. CMS instructs contractors on how to prevent the misuse of modifiers PA, PB, and PC in Transmittal 1867, Change Request 6718, issued Dec. 4.

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