Oncology & Hematology Coding Alert

Oncology practices that perform diagnostic testing procedures in a hospital could be overbilling Medicare or be subject to repeat denials if they fail to use modifier
-26 (professional component) to separate the physician component from the facility-billed technical component.

One example can be found in diagnostic mammography. The radiological procedure is furnished to men or women with signs and symptoms of breast disease, a personal history of breast cancer, a personal history of biopsy-proven benign breast disease or abnormal findings on a screening mammogram. In some situations, oncologists must rely on a hospital to provide the service in this case, outpatient radiology for diagnostic mammography. But oncology practices sometimes assume incorrectly that they are entitled to the entire payment, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a Dallas, Ga.-based coding consulting firm. A doctor may order the test and think he or she can bill for it, she says. You must perform the service to bill for it.

Modifier -26 Shows Physicians Role in Hospital Test

When the physician who ordered the test to be performed in a hospital also completes the interpretation and report, it must be specified that he or she is responsible for only the professional component of the test. The oncologist must also note that the hospital is responsible for the technical component. In the above case, the physician would bill using 76090 (mammography; unilateral) and 76091 (mammography; bilateral).

The oncology practice that performs the interpretation, dictates the report and bills for these tests must attach modifier -26 to these codes to define its role in the service. Diagnostic mammography typically is not payable when the test is obtained for screening purposes or for tests obtained for non-medically indicated reasons. Diagnosis codes such as breast cancer (174.0-175.9) and abnormal mammogram (793.8) generally meet the medical-necessity guideline for an insurance payer.

But failing to use modifier -26 appropriately has a double edge, says Laurie Castillo, MA, CPC, president of the American Academy of Professional Coders (AAPC) Northern Virginia chapter and president of Physicians Coding and Compliance Consulting in Manassas, Va. I see this a lot in physician practices. They either bill for the service and forget to use modifier -26, or they assume that because the procedure was done in the hospital that they cant bill for it, she says. By not using modifier -26, they are not getting paid for something they deserve.

Technical vs. Professional Components

Failing to separate the technical component and the professional component can lead to claim denial. Because the service was delivered in a hospital, Medicare will declare that the hospital is entitled to bill for the service, or the carrier will automatically reduce payment. Certain procedures, such as diagnostic mammography, are actually a combination of a physician component and a technical component.

The technical component consists of the room where the test was performed, the equipment used, supplies provided by the hospital and the technicians salary services paid by the hospital. The professional component, on the other hand, is the skill and expertise of the physician who interpreted the test results.

To receive reimbursement for the professional component provided in a hospital outpatient department, oncology physicians must attach modifier -26 to the radiology CPT code. The only exception is the physician who is billing a global fee. In this instance, no modifier is needed. If more than one modifier is needed, place modifier -26 in position one on the HCFA-1500 form and the other modifier in position two.

As always, documentation is important. The patient record should include the name of the physician who ordered the diagnostic mammogram. The diagnosis code listed on the claim must reflect the primary indication for the service performed and be corroborated by the medical information on the mammogram report.