Wiki Modifier 26

[jodonnell1]

Both UMR and Meritain as a claims processor have been denying some lab/radiology professional charges for Modifier 26. They say they will process the claim without modifier 26. The explanation is that the technician is just watching the results and not doing anything. Any thoughts?

 

[thomas7331]

It would depend on the CPT or HCPCS code - can you provide any examples of what services you're seeing denied?

Many codes, especially most clinical laboratory services, do not have a professional component, so those would not properly be billed with this modifier since there is no separate professional work involved in performing an interpretation. Most payers would have published written reimbursement policies regarding this, which would explain when, why and how they will process these claims which would give you additional detail about their reasoning and expectation for billing and payment.