Modifier 26 - surgery codes

donnajrichmond

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I've always been told that Modifier 26 should not be used with surgery codes, and the MFSDB gives surgery codes a PC/TC indicator of 0 or 9. But I can't find anything specific from CPT that says that modifier 26 is not for surgery codes (specifically 10022 in the case in question, but any comment would help). Does anybody have any non-medicare reference to this?
 

kevbshields

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Donna:

I cannot site a specific reference here, but I can comment and advise a little. Primarily I want to say, use an encoder software program that assigns mods. There are a couple out there. Point being, the encoder logic will not allow certain modifiers to be assigned to specific CPT (usually surgery, EM, etc) codes, as they are invalid modifiers that defy the logic of the code's descriptor. For example, if we look up 10022 on encoderpro by Ingenix, modifier -26 is not permitted, as it violates the logic of the code.

Also, if we look at the CPT Surgery section notes, common modifiers are listed there (e.g., 51,58, etc). -26 is not mentioned. Also the definition of Modifier -26 in the Appendix A of CPT says "certain procedures," meaning that not all procedures would have both a TC and PC componant.

In addition, as you know, I'm sure, the imaging guidance procedure that would be reported with this code would have a valid professional and technical breakdown. The surgery code should not.

I'm not sure exactly what you're looking for, but this is an explanation that I hope helps. Of course, there might be some commentary in one of the AMA books on modifiers. Not sure what you're seeing on your end, but you can always email me off-forum and I can see what I can do. (kevbshields@yahoo.com)
 
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