Orthopedic Coding Alert

Do you know when to use professional component modifier?

There are times when your orthopedist will provide only a portion of a service represented by a particular CPT^® code.

When this occurs, you might need help from a couple of modifiers in order to untangle your practice’s deserved reimbursement from the other relative value units (RVUs) of the CPT^® code.

Enter 26, 54: Modifiers 26 (Professional component) and 54 (Surgical care only) are frequently used in these situations to show the payer that you are only coding for the portion of the service your surgeon performs. Check out our expert advice on best use of modifiers 26 and 54.

Professional Component Only? Use 26

According to Kelly Dennis, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla., “some procedures are a combination of both a physician component and a technical component. Using modifier 26 identifies the physician’s component. When a 26 modifier is reported, it reduces payment to just the physicians work, not the cost of the equipment.”

Example: A patient comes in for a visit, and after a low-level evaluation and management (E/M) visit, the provider sends the patient down the hall for an X-ray of the right wrist with four views. Once that is performed, the doctor does the official writing up of the report.

On this claim, you’ll report 73110 (Radiologic examination, wrist; complete, minimum of 3 views) for the X-ray with modifier 26 and modifier RT (Right side) attached. “The technical component of actually capturing the views was done by the facility; and thus, they will bill that portion with a TC [Technical component] modifier. The physician, on the other hand, will use the 26 modifier to illustrate his involvement in the service,” according to Hauptman.

Use This Advice for 26 Success

There are consequences for not using modifier 26 when appropriate, Hauptman warns. “You may get paid in full for a service you did not totally perform; or you may not get paid at all,” she says.

You also need to mind the Office of Inspector General (OIG), “as it watches the professional services, and the 26 modifier, very carefully,” she continues.

In order to ensure proper modifier 26 use, Hauptman encourages coders to follow these basic guidelines:

• “Understand what is included in the description of the code — some codes are for only the professional component and you wouldn’t need the 26 modifier;
• “Understand exactly what your physician did and read the documentation associated with the service;
• “Know what equipment is owned by your practice and what is owned by the various facilities where your doctor sees patients.
• “Understand the relationship your physician has with the facility, as they might bill the global fee and pay the physician based on a contract.”

Surgical Component Only? Use 54

Another instance where you would be coding only for a portion of the service involves surgeries, and modifier 54. Use 54 “when the physician provides only the surgical procedure — pre-op and intraoperative care — and another physician provides post-op care,” explains Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, N.J.

There are several situations in which a coder might use modifier 54 — often involving people who don’t live in your area and won’t be around for postoperative care.

Remember: A coder should only append modifier 54 to the procedure code when your provider reaches an agreement with the patient (and their payer) about providing surgical care only. The provider must know that the patient will obtain postoperative care elsewhere before taking on the surgery.

Example: A patient who is in the area skiing suffers a right ulnar shaft fracture. The surgeon performs open reduction and internal fixation of the shaft. Notes indicate that the patient will return home before they need postoperative care, and a surgeon local to the patient will provide post-op care. There is documentation to attest to the fact that another surgeon will handle post-op care in the notes.

On this claim, you’ll report 25545 (Open treatment of ulnar shaft fracture, includes internal fixation, when performed) with modifiers 54 and RT (Right side) appended.