Cardiology Coding Alert

Avoid false claims by signifying purchased technical components

If your cardiologist performs and supervises a diagnostic stress test (such as a myocardial perfusion study) using in-house equipment, but another physician does the interpretation, you should not append modifier -26 (Professional component) to the diagnostic test code but use modifier -TC (Technical component) instead.

But that rule can change if your practice purchases the technical component from an independent physician, medical group, or supplier.

A provider that does not own the diagnostic equipment or employ the necessary staff may purchase technical and/or professional components from another supplier and potentially receive reimbursement for the global code, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.

Differentiate Between Professional and Technical Components

Certain CPT codes, such as those for myocardial perfusion studies (78465, Myocardial perfusion imaging;
tomographic [SPECT], multiple studies, at rest and/or stress [exercise and/or pharmacologic] and redistribution and/or rest injection, with or without quantification), consist of two components: the technical component (modifier -TC) and the professional component (modifier -26).

"TC is for the entity that owns the equipment," says Peggy Stilley, CPC, office manager for Women's Healthcare Specialists, an Oklahoma University-based private physician practice in Tulsa, "and the -26 is for the professional interpretation."

Modifier -26: If your cardiologist performs a myocardial perfusion study with hospital equipment, you should use 78465 and append modifier -26 to reflect that he performed the service, interpreted the findings, and wrote the report.

"You should not use modifier -26 with procedures that are either 100 percent technical or 100 percent professional," says Lisa Center, CPC, quality coordinator with Freeman Health System in Joplin, Mo. "You should only use it on procedures having both components."

Modifier -TC: In the same scenario above, the hospital would then report the myocardial perfusion study code 78465 using modifier -TC for their portion of the test. Modifier -TC indicates to the payer that the hospital only supplied the technical component but not the professional interpretation, Hammer says.

Both -26 and TC: If the cardiologist performs both technical and professional components, he should submit a CMS-1500 form with the CPT code and no modifier to indicate he provided the global procedure, Hammer says.

For example, a cardiologist orders a myocardial perfusion study and interprets and documents the findings. He owns or leases the equipment involved and employs a nuclear tech. In this scenario, the cardiologist performed the global procedure and would submit the CMS-1500 with code 78465. He will be reimbursed for the entire global relative value unit (RVU) amount.

According to Regence BlueCross BlueShield of Oregon, "A 'complete' procedure (that is, professional plus technical component) billed with no modifier attached to the procedure code, is only eligible for reporting and reimbursement when that provider owns the equipment and is also providing the professional component."

Avoid 2 Major Pitfalls of Purchased Technical Components

But suppose that your cardiologist does not have the capability to perform a myocardial perfusion study (or other diagnostic test) inside his office. Instead, he contracts with another physician, medical group, or supplier to perform the technical component for him - such as a mobile imaging lab.

MCM Publication 100-04, Chapter 1, 30.2.9, Payment to Physician for Purchased Diagnostic Tests - Claims Submitted to Carriers, states, "A physician or medical group may submit the claim and (if assignment is accepted) receive the Part B payment, for the technical component of diagnostic tests which the physician or group purchases from an independent physician, medical group, or supplier."

"When you purchase the technical component, you have to list the provider number of the entity you purchased from," says Alice G. Gosfield, attorney at law at Alice G. Gosfield & Associates in Philadelphia. "The implication is that you can only deal with a Medicare- recognized entity." 

Always Report Purchased Technical Components and Don't Mark Up Price

According to MCM Part 3, you should not submit a global code on your claim when your practice purchased one component of the service. "You bill it as split-billed. In other words, you use modifier -26 for your own piece, and the -TC is billed as a purchased modifier," Gosfield says.

Pitfall #1: Always be sure to indicate when you purchased the technical component. "If you don't indicate that you purchased it, then you have a potential false claim," Gosfield says.

According to Trailblazer Health, a Medicare Part B carrier of the District of Columbia, you may not submit a global code when your practice purchases one component. You should submit the technical (modifier -TC) and professional components (modifier -26) on separate lines or separate claims depending on how you file them so the carriers can determine payment jurisdiction and price services correctly.

Reporting your myocardial perfusion study code (78465) this way still means that you'll be paid as if you reported the code without any modifiers. "The components should add up for the same amount as if you had billed globally," Gosfield says.

Pitfall #2: If you purchase the technical component, you are not allowed to mark up the price. "What you have to put down as the charge is the fee schedule amount or the actual amount you paid - whatever is less," Gosfield says.

Prior to reporting for purchased test components, make sure to consult with your attorney about other regulatory concerns before changing any practices.