Wiki Hospital billing of modifier TC

[rhood151]

I'm conducting an audit of a TPA and am claiming that there is double billing when a hospital bills a radiology procedure without a modifier (global) and an unrelated physician bills the professional component, there is double payment for the professional component. The TPA is claiming that whenever a hospital bills a code such as radiology, it is "understood" that it is for the technical component only, even though there is no modifier. According to the TPA, if another provider, not an employee, then bills for the professional component, my claim that the professional component is double billed is incorrect because only the technical component was paid to the hospital.
Are different rules applied if the patient is inpatient vs outpatient? For instance does the DRG payment include only the technical component?
Has anyone heard of this "understood" rule that hospitals bill for the technical component only even without a modifier?
Does anyone know of a policy/rule addressing this that would be considered to be a billing standard that can be cited in court? My searches have turned up nothing that would be considered as an authority.

 

[aaron.lucas]

That is not correct, we should always remember that unless there are parenthetical notes or guidelines spelling it out, nothing is ever "understood" or "assumed" when it comes to coding and billing. If a procedure that has both a professional and technical component is billed without a modifier, it is considered global. The DRG can't pay only technical because the fact that something was done inpatient doesn't necessarily mean that the radiology isn't outsourced somehow. Many hospitals have an outside radiology company doing the interpretation and report, so regardless of the status of the patient (in or out), the hospital can only bill technical. As far as policies/rules go, I would with the modifier descriptions in CPT/HCPCS. The description for modifier -TC in the HCPCS book is pretty detailed. Otherwise I would just argue that it's correct coding to use modifiers when they are appropriate to ensure proper reimbursement. That's just something that every coder knows, it's not a big secret. Does the TPA employ any coders? If so they should know better, and if not then you may have leverage there, because you're the subject matter expert when arguing coding policies and guidelines. Hope I could help. Anybody else wanna weigh in?

 

[kevbshields]

The hospital line item for the radiology payment is driven by the revenue code, which will indicate that only the "technical" charge is included. For hospital billing, it is understood that only the technical component is collected and charged, unless otherwise indicated (e.g., radiologists under contract with the hospital and it bills 2 line items with different rev codes to indicate both pieces).

DRGs represent only the technical component, yes. That is why physicians (or the hospitals who employ them) bill out professional services on the CMS 1500 for admission, discharge and other CPT-driven (professional) services. Pro fees are never included in the DRG, under standard payment arrangements.

As for this being written, I could not answer that. However, if you read the UB claims manual from Medicare and fully understand the revenue coding system, then you will understand that modifiers are unnecessary on institutional claims (at least, the TC, 26 and some others), meaning the UB-04.

Hope this helps.