Wiki Modifier 25 & TC

[pittiemom2722]

Hoping someone can clarify for me as I'm confused. I've been billing in a private ortho practice for several years and we recently merged with a local hospital so we're now technically an outpatient facility. There are several insurance carriers that require split billing. What I'm told from the hospital billing dept is that a 25 is required on the TC component for the E/M portion of the claim if any x-rays are done here in the office which I've never had to do before. I'm not familiar with outpatient billing at all so I've been trying to do my own research on this and I'm confused with status indicators, etc., so sometimes I think yes and sometimes I think no. Most of the films we do in the office are listed on the CMS site as indicator Q1.

With that being said, is 25 required on the TC component of my E/M??? It's very confusing with the entire explanation of how all of these things work so I'm guess I'm looking for a straight 'yes' or 'no' and then maybe I'll 'get it'.

Thank you for any help in clarification!!!

 

[thomas7331]

Provider-based billing is indeed very confusing. There is no 'TC component' of an E/M charge, but I think you mean the corresponding facility fee/clinic visit charge that the hospital can bill - if billing Medicare your E/M service that will translate to G0463 for the facility portion. The Q1 status codes are conditionally packaged into the medical visit, and payment is sometimes not made separately for that charge, depending on cost. If not packaged, the modifier 25 will be required, but it will not, to my knowledge, cause a denial if packaged either, so we always add the 25 modifier to our E/M codes when billing together with an X-ray. Hope this helps some.