Capture Total Service or Procedure with 26 and TC
Don’t settle for a portion of payment—get the full amount.
By Meera Mohanakrishnan, CPC, CPC-H
Frequently, the total service/procedure described by a single CPT® code is comprised of two distinct portions: a professional component and a technical component.
The professional component of a diagnostic service/procedure is provided by the physician, and may include supervision, interpretation, and a written report. The extent and nature of the professional component depends on the precise service/procedure rendered. For example, a written report generally is required, but may not be necessary for a supervising pathologist to claim professional services in a clinical laboratory (see “Professional Services in the Clinical Lab: Billable or Not?” Coding Edge, July 2009, pages 48-49). When required, the interpretation of a diagnostic test should be a separate report, signed by the physician.
The technical component of a diagnostic service/procedure accounts for equipment, supplies, and clinical staff (such as technicians). Payment for the technical component also includes the practice and malpractice expenses. Fees for the technical component generally are reimbursed to the facility or practice that provides or pays for equipment, supplies, and/or clinical staff.
Procedures/services that may include both a professional and technical component are found commonly within the Radiology, Pathology and Laboratory, and Medicine chapters of CPT®. The surest way to identify codes with separate professional and technical components for Medicare payers is to consult the National Physician Fee Schedule Relative Value File, available for download on the Centers for Medicare & Medicaid Services (CMS) Web site. (The most recent file as of January 2010 may be found at: www.cms.hhs.gov/PhysicianFeeSched/pfsrvf/list.asp?listpage=4.) If the Relative Value File lists separate line items for a code with modifiers 26 Professional component and TC Technical component, the service/procedure described by that code includes both a technical and professional component.
For example, the 2010 Relative Value File lists three separate lines for 70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material. The first of these lines corresponds to the “global” service, which is assigned 6.10 relative value units (RVUs) (all RVUs cited are fully implemented facility and non-facility totals). The second line details the technical component only, with 4.37 total RVUs. The third line describes the professional component of 70480, at 1.73 RVUs. Note that the RVUs for the technical and professional components will equal the total RVUs for the global service (4.37 + 1.73 = 6.10).
Professional Services Call for Modifier 26
Separate payment can be made for the technical and professional components of a procedure when each is performed by different professional providers. For instance, the technical component of a service/procedure may be performed by the clinic, but the professional component is performed by an outside physician or laboratory. In such situations, providers must submit their claim and bill only for the service performed.
To identify professional services only for a service/procedure that includes both professional and technical components, append modifier 26 to the appropriate CPT® code, as instructed in CPT® Appendix A, “Modifiers.” Note that modifier 26 is appropriate when the physician supervises and/or interprets a diagnostic test, even if he or she does not perform the test personally.
When only the professional component of a service is provided, failure to report modifier 26 will cause the claims to adjudicate incorrectly and lead to recovery as permitted by law. Modifier 26 should not be used, however, if there is a specific code that already describes only the professional/physician component of a given service. For example, it is inappropriate to append modifier 26 to 93722 Plethysmography, total body; interpretation and report only because the code does not include a technical component, but describes professional services solely.
Modifier TC Identifies Technical Component Only
Appending modifier TC indicates that only the technical component of a service/procedure has been provided. Generally, the technical component of a service/procedure is billed by the entity that provides the testing equipment.
Note that physicians providing services for Medicare patients in a hospital or facility setting cannot claim the technical portion of a procedure regardless of whether the physician owns the testing equipment. Under the diagnosis-related group (DRG), the hospital/facility receives payment for the technical component of Medicare inpatient services. Similarly, Medicare rules require payment for non-physician services provided to hospital patients (such as the services of a technician administering a diagnostic test) to be made to the hospital.
Just as there are codes describing professional-only services for Medicare, so are there codes describing technical component-only services. Do not apply modifier TC (or 26) with such codes. For example, 93005 Electrocardiogram; tracing only, without interpretation and report is covered only as a diagnostic tests and does not have a related professional code. The total RVUs for technical component-only codes include values for practice and malpractice expenses only.
Global Billing Doesn’t Require 26/TC
As explained previously, the global service includes both the professional and technical components of a single service. When reporting a global service, no modifiers are necessary to gain payment for both components of the service. Never report a single procedure code with both modifiers 26 and TC.
For example: Code 76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete describes a service that includes both a technical component (the ultrasound machine, along with necessary supplies and clinical staff to support its use) and a professional component (physician supervision, interpretation, and report).
If pelvic ultrasound is performed at the physician’s office, either by a physician or a technician employed by the practice, the physician reports 76856 without a modifier because the practice provided both components of the service.
On other hand, if the physician performs the same procedure at the hospital, the physician would report 76856-26 for the professional component only. The hospital would claim separate reimbursement for the technical component (76856–TC) because it owns the ultrasound equipment.
Note that in all reported cases, modifiers 26 and TC are considered payment modifiers and must be reported in the first modifier field.