Otolaryngology Coding Alert

Question: What are the guidelines for reporting professional services? South Dakota Subscriber Answer: When an otolaryngologist conducts diagnostic tests or other services using equipment supplied by a hospital or other facility, he or she must append modifier -26 (Professional component) to the appropriate CPT code to indicate that only the physician component (e.g., administration or interpretation) of the service was provided. Appendix A of CPT explains that some procedures are a combination of a physician component and a technical component. "When the physician component is reported separately," CPT further specifies, "the service may be identified by adding modifier -26 to the usual procedure number" or by attaching the five-digit modifier code 09926. The easiest way to determine if a CPT code contains both a professional and technical component is to consult the National Physician Fee Schedule Relative Value Guide. Check the far left-hand column that lists each individual CPT code. If the fee schedule lists separate values for the code with modifiers -26 and -TC (Technical component), modifier -26 is appropriate for that code if only the professional component of the service is provided (i.e., meaning the physician does not own the equipment that he or she uses to provide the service). Typically, the technical component (-TC) reflects the practice expense and malpractice RVUs, while the professional component (-26) reflects the work RVUs only. When the physician reports a procedure with modifier -26, the facility will bill separately, appending modifier -TC to the procedure code to receive compensation for use of its equipment. If the otolaryngologist fails to append modifier -26, the technical portion of the service will have been double-billed, which could lead to accusations of fraud or a demand for repayment.