Wiki Dual Fee Schedules for Modifier 26?

[ellenroberts]

During a discussion today, it was discovered that some practices think that you must reduce your fee when billing with a Modifier 26. I contend that the Payer reduces the PAYMENT based on the Modifier, and that the Fee should always be billed the same with or without the modifer used. Now I have to show documentation to that effect. Can anyone point me to a source for this?

 

[Pam Warren]

You are right in that you must bill all services 'the same'. But the modifer on a charge differentiates the charge from the global fee, so technically, they're not the same charge. So you may (and should) adjust your fees when billing pro-fee services, although not everyone follows this business model.

Reference the payment information for all codes, all modifiers on the PFS section of the CMS website. It will tell you the reimbursement based on global, -26 and -TC, and based on facility or non-facility site of service. You may then adjust your fees accordingly. http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx


For example, 93279 billed globally is reimbursed 50.72 by (national) Medicare when billed from a non-facility. 93279-26 is reimbursed 32.68, and the -TC is 18.04. If we were to bill the -26 based on a global charge of 50.72, we'd have to take a larger adjustment when the claim was adjudicated...and we've technically overbilled Medicare. (they won't pay it...but then our adjustments are over-inflated). We've hard-coded the CPTs in our billing system to allow us to select either 93279, or 92379-26, depending on which way we can bill it for that service. This allows us to drop the appropriate charge amount, depending on if the modifier is billed or not. It's a lot of work when we update our fee schedule but worth it in the long run.

So, we do adjust our fees, based on whether we bill globally or for pro-fee only.