Pediatric Coding Alert

If your practice owns the equipment, you can code without modifier.

When your pediatrician provides services for a patient using another facility’s equipment, payers will only reimburse for her interpretation services.

How? Appending modifier 26 (Professional component) shows the payer that you are only coding for your provider’s services, not the equipment she used (often referred to as the technical component).

Read on for advice on using this modifier properly, avoiding payer suspicion, and getting every dollar you deserve out of your claims.

Some procedures are a combination of both a physician component and a technical component.

“Using modifier 26 identifies the physician’s component,” explains Kelly Dennis, CANPC, CHCA, CPC, CPC-I,  owner of Perfect Office Solutions in Leesburg, Fla.

Report modifier 26 when a code “includes the technical component as well as the professional component,” but your provider only performs the professional component, explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med Group in Pittsburgh, Pa.

When you use modifier 26, “it reduces [code] payment to just the physician’s work, not the cost of the equipment,” Dennis confirms.

Setting: Keep an eye out for claims in which the provider performed services in hospital observation units, emergency departments (EDs), or outpatient facilities, as they will be potential modifier 26 hotspots. In short, any time the equipment is the property of the clinic or facility and not your pediatrician, you’ll need to append modifier 26 to your code, Hauptman confirms.

Example: A new patient reports to your practice, located in a hospital. After performing a detailed history and exam, along with moderate medical decision making, the pediatrician decides to send the patient down the hall for a chest x-ray. Notes indicate that the pediatrician ordered and interpreted a single-view frontal chest x-ray. On the claim, you would report

• 71010 (Radiologic examination, chest; single view, frontal) for the chest x-ray
• Modifier 26 appended to xx to show that you are only coding for the professional component
• 99203 for the evaluation and management (E/M) service
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99203 to show that the E/M and x-ray were separate services.

Rationale: The pediatrician “doesn’t own the equipment down the hall as it is part of the hospital,” so you should report modifier 26, Hauptman confirms.

In general, you’ll use modifier 26 most often when the pediatrician conducts a diagnostic test or a radiologic service that has a technical and professional component.

Chest x-rays: In addition to 71010, the pediatrician might perform other chest x-rays, such as 71020 (Radiologic examination, chest, 2 views, frontal and lateral) and 71035 (Radiologic examination, chest, special views [e.g., lateral decubitus, Bucky studies])

Ensure Proper Modifier Use Pre-Submission

If you do not use modifier 26 when the encounter calls for it, “you will get paid in full for a service you did not totally perform,” explains Hauptman.

Great, right? No, it isn’t.

Consequences: If you have collected cash for technical components and the payer discovers it, they’ll be coming back for that money. Remember, “it is important to make sure you recoup only the money for the professional component” when your pediatrician doesn’t provide the technical component of the code.

Not only are payers watching; the government is, too. “The OIG [Office of Inspector General] watches the professional services and the 26 modifier very carefully. Make sure you understand all [modifier 26] requirements,” Hauptman recommends.

Best bet: According to Hauptman, the easiest way to make sure you use modifier 26 correctly is to:

• “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; and
• Know what equipment your practice owns, and what is owned by the various facilities where your doctor sees patients.”