Neurology & Pain Management Coding Alert

If a physician conducts diagnostic tests or other services using equipment she doesn't own, modifier -26 (Professional component) is appropriate to indicate that she provided only the physician component (the administration or interpretation) of the service. But using modifier -26 in the facility setting is not always so straightforward. By reviewing CPT and CMS guidelines, you can easily append the modifier like a pro, every time. Separate the Technical and Professional Appendix A ("Modifiers") of CPT explains that some procedures are a combination of a a technical component and a physician (or professional) component. If the physician provides both components of the service, he or she may report the appropriate CPT code with no modifiers. But "When the physician component is reported separately," CPT specifies, "the service may be identified by adding modifier '-26'to the usual procedure number." In the latter case, the facility providing the equipment may claim the "technical component" of the service (the cost of equipment, supplies, technician salaries, etc.) by reporting the appropriate CPT code with modifier -TC (Technical component) appended. Many radiologic and diagnostic procedures requiring specialized equipment contain a professional and technical component, but the surest way to tell is to consult the CMS Physician Fee Schedule. Check the far left-hand column that lists each individual CPTcode. If the fee schedule lists separate values for the code with modifiers -26 and -TC, modifier -26 is appropriate for that code if the physician provides only the service's professional component. Note: The Physician Fee Schedule, updated annually, is available as a free download at the CMS Web site: http://cms.hhs.gov/physicians/pfs/. For example, the fee schedule lists values for both professional and technical components (0.26 and 0.89 relative value units, or RVUs, respectively) for nerve conduction study code 95903 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study). In other words, the full value of the code (1.15 RVUs) includes performance of the study, interpretation and report, as well as a fee for equipment, staff, etc. Therefore, if the neurologist performs the test using equipment owned by a hospital or other facility and provides interpretation only, he must append modifier -26 to 95903. The facility will bill separately, appending modifier -TC to 95903 to receive compensation for use of its equipment. If the neurologist fails to append modifier -26 and the facility nonetheless bills with modifier -TC, the technical portion of the service will have been double-billed, which could lead to accusations of fraud or a demand for repayment. It's Not All About Who Owns the Equipment When determining if modifier -26 is appropriate, it's not always as simple as asking, "Does the physician own the equipment?" When billing Medicare, for instance, physicians providing [...]