Wiki Hospital use of modifier TC


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I am conducting an audit and being told by the TPA that when a hospital bills for a radiology procedure for example, that it is "understood" that it is for the technical component only. They don't need to add the modifier TC. I am seeing many instances of what appears to be global billing by the hospital and the professional component by the physician. I am considering this to be double billing of the professional component. Has anyone heard of this "understood" rule about modifier TC by a hospital?
I would not understand why there would even be an "understanding" that the hospital can bill globally and assume the insurance companies "understand" that they are only billing for the technical component.

I bill radiology for a non-profit community based clinic (FQHC). We bill global Rad. codes for everything except mammos for medicare, and U.S. for Aetna. The reason for this is because they will only pay the technical component, so we have to unbundle (per medicare guidelines) and bill the Technical and Professional components seperately, otherwise is will be denied all together.

So maybe there is something with your contracts that requires this type of billing, I would review the contracts and look up the billing guidelines on the payors websites.

Also, you should probably find out if the Rad equipment is owned by a different organization than the providers work for. For example, I previously worked at a hospital that owned the equipment, but some of the providers worked for a different organization and simply worked the outpatient clinics at this hospital...

I still agree with you that it seems the technical component is being double billed. :D
The double line billing is an FQHC rule for Medicare. Facilities bill global because they own the equipment and the radiologist that provides the interpretation is their employee. If the provider is billing with a 26 modifier you need to see if the radiologist provided an interpretation. If not then the hospital can bill only the TC modifier. Then if there is no separate interpretation from the provider, not just a notation in the progress note, he cannot bill for it.
Hospital use of Modifier TC

We're about to go to war on this issue and others. 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. My claim is that the global and professional component have been paid to two unrelated providers resulting in a double payment of the professional component.
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.