Wiki billing 20610 and 77002 for Professional claim vs Technical

[megibabe@hotmail.com]

Hoping someone can help!
I work for a billing company for a group of radiologists who perform 20610 along with other injection/biopsy procedures under flouro guidance in a facility that is separately owned and operated. It has come to our attention that the facility has been billing for this charge as well. My gut is telling me this is not correct. However, it doesn't seem that we can append a 26 mod to this charge.

In this case should only one entity be billing for this service? Is there a known modifier or additional code that should be placed on either the UB or 1500 form?

The facility is only providing the place of service and the equipment while our radiologist is doing everything else.

Any help is truly appreciated, thank you in advance!

 

[cgaston]

This is exactly what the -26 modifier is for!

Only if a provider provides the service and owns the equipment he/she can bill global (no modifiers). The technical component of a service (TC) covers the fees for the room/equipment and the professional component (26) covers the physician's work.

In your case, the hospital would bill the 77002-TC modifier and your provider would bill 77002-26.

 

[megibabe@hotmail.com]

Thank you! Understood with the modifier for the flouro charge however what about the 20610? This charge is exempt from a 26 mod.

 

[thomas7331]

Thank you! Understood with the modifier for the flouro charge however what about the 20610? This charge is exempt from a 26 mod.

Surgical codes such as 20610 do not have a professional or technical component, so no modifier is required. The facility vs. non-facility payment level assigned for these codes is based on the place of service billed on the claim form, so as long as your place of service code correctly reflects that the service was performed in a hospital, then your payments should also be correct in that only the professional services will be included in the rate calculation.

 

[cgaston]

The provider who performs the injection should be the provider billing for the service.

The physicians should discuss this with the facility to find out why the facility thinks they are entitled to bill for the physician's services (there could be something in the contract that everyone is unaware of).

 

[thomas7331]

The provider who performs the injection should be the provider billing for the service.

The physicians should discuss this with the facility to find out why the facility thinks they are entitled to bill for the physician's services (there could be something in the contract that everyone is unaware of).

Facilities do use the same CPT codes as the physicians, but the facility is not billing for the physician's services - they are just using those codes to report what procedures were done in that location. Hospital claims are submitted a UB form which only represents charges for the facility's portion of the costs of doing that procedure. Facility reimbursement is a completely separate payment process from physician, and compensates the facility for supplies, staff time, use of the space, etc. The fact that they use the same CPT code does not mean they are duplicate billing for the same service as the physician.

 

[mitchellde]

The provider who performs the injection should be the provider billing for the service.

The physicians should discuss this with the facility to find out why the facility thinks they are entitled to bill for the physician's services (there could be something in the contract that everyone is unaware of).

Thomas is correct, reimbursement for services in the range 10000-69999 is driven by place of service not professional vs technical. So both the provider and the facility bill these services, the provider reimbursement will be the correct amount for being in a facility as opposed to being on the office setting.
The facility is entitled to some of the reimbursement for the use of the facility and the facilities resources, with it they could not stay in business.