Modifier -26 on labs?

Lisa Bledsoe

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I don't do laboratory coding but was shocked that a pathologist charged me for the professional component of lab tests (80053-26, 80061-26, 84439-26, 84443-26, 85025-26). As far as I am aware these codes cannot be reported with modifier -26. The person at the pathologist office told me that they CAN use mod -26 and charge me the professional fee. Someone please tell me - is this truly appropriate?
Thank you!
 

efrohna

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I don't do laboratory coding but was shocked that a pathologist charged me for the professional component of lab tests (80053-26, 80061-26, 84439-26, 84443-26, 85025-26). As far as I am aware these codes cannot be reported with modifier -26. The person at the pathologist office told me that they CAN use mod -26 and charge me the professional fee. Someone please tell me - is this truly appropriate?
Thank you!

Lisa,
You are correct, this is not appropriate. I checked all the labs you indicated above. Here is the last one that I copied & pasted for your review. The same language appeared on the other labs as well. I bolded your answer below. Good luck.

85025 Complete cbc w/auto diff wbc - PC/TC Not Applicable
General Information

Code: 85025
Description: Complete cbc w/auto diff wbc
PC/TC Indicator: 9: Not Applicable code.Concept of a professional/technical component does not apply.
Last Updated: 01/01/2009
 
Last edited:

tomtom2

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Lisa,

Professional component billing for pathology service is appropriate. It is also recognized by the AMA (sorry Evangelina). This is billed by the hospital based pathologists for the supervision of the laboratory. Although they may not personally perform the test or review the results, the pathologist are responsible for supervising the laboratory to assure clear, timely, and clinically reliable reporting of test to your doctor. When you were admitted to the hospital you were probably explain this in your patient agreement and consent form that you signed.
 

Lisa Bledsoe

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Tomtom - These were tests that were drawn at my physician's office and sent to an outside lab (in this case Frontline Lab). There were no "pathology specimens". The professional component that I was charged for came from a local pathology office. I do not see the connection and I do not agree that a professional component can be charged to the patient when the tests are automated at an outside lab that would be overseen by a pathologist located there. Modifier -26 is not a valid modifier for any of the tests I had done. In the end, my insurance informed the pathology office billing me the professional component that this was not a valid coding procedure and I am not liable for it. It all worked out, I am just annoyed that this occured.
Lisa
 

Anna Weaver

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modifier 26 on labs

Lisa,
I'm glad it worked in your favor, I agree with you, there should not have been a 26 on any of these codes. The only laboratory codes I have found that require (or are able to use) a 26 are on pathology, histochemistry, histocytopathology. These all require a review by the pathologist therefore, a 26 is appropriate. The codes you mentioned are not normally reviewed by a pathologist and are interpreted by your PCP. (this is my opinion).
 

tomtom2

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Lisa,

Sorry didn't know this was an outside lab. Outside labs should not split bill automated test. Hospital labs vs outside labs is two different stories.:)
 

larsenmm

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We have pathology labs that processed and read by a pathologist at one practice. The patient has now come to our practice and the pathologist here reviewed the records from the first pathologist and now our pathologist wants to bill for them. Is that allowed?
 

aleigh

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It is allowed, and paid by select insurances. For the client I bill for it is policy to bill the insurance and if they don't cover the services then we write it off. But I have heard of some practices that do charge the patient for this, doesn't seem right to me.
 
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Hello,
I am with a new group who is looking to perform genetic/molecular testing. I have always understood that labs are not billed with a TC/26, however, does this also hold true for genetic/molecular codes? (0037U, 81479, 81454) since these are reviewed by a Pathologist?
 

lcolborn

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Lisa,

So glad all went well for you on the labs. Seems to me the clinic you had the labs have a contract with the pathologist that interpreted the result and you may want to watch out for another bill for the TC component . It's no likely to happen, but it could. I code for a Independent Lab and if a test is not paid as a whole , we try to at least get paid for the TC component or vice versa.
 
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