Wiki PROFESSIONAL COMPONENT (26) FOR XRAYS ON UB04

[aarms]

I bill for a physician office/family practice that is owned by a hospital. I am getting denials from Medicare for billing our xrays with modifier 26 on the UB04 (Example: 71045 -26)
The hospital bills the "TC" & their claims are processing without issue, but mine all state "Returned."
I have spoke with multiple medicare reps and cant get a clear answer. Can anyone help on what I may be doing wrong or suggestions to try?

 

[sls314]

I bill for a physician office/family practice that is owned by a hospital. I am getting denials from Medicare for billing our xrays with modifier 26 on the UB04 (Example: 71045 -26)
The hospital bills the "TC" & their claims are processing without issue, but mine all state "Returned."
I have spoke with multiple medicare reps and cant get a clear answer. Can anyone help on what I may be doing wrong or suggestions to try?

Why aren't you billing professional fees on a CMS 1500? Are you a critical access hospital?

Do you bill under the hospital tax ID? If you're billing under the hospital tax ID on a UB-04, it is probably conflicting with the TC claim. In that case, perhaps there should be one claim with the global code. However, if the facility is a critical access hospital, there are special rules so you may want to get some input from other CAH billers.

 

[emarshall]

I bill for a physician office/family practice that is owned by a hospital. I am getting denials from Medicare for billing our xrays with modifier 26 on the UB04 (Example: 71045 -26)
The hospital bills the "TC" & their claims are processing without issue, but mine all state "Returned."
I have spoke with multiple medicare reps and cant get a clear answer. Can anyone help on what I may be doing wrong or suggestions to try?

It may be one of 2 things..either you should be billed on a hcfa-1500 with POS 11. Or because the hospital owns the equipment and the office is under the same tax id as the hospital, that code is part of the global package POS 21 or 22, meaning the interpretation can not be billed separately by the physician in that POS setting.

 

[aarms]

Why aren't you billing professional fees on a CMS 1500? Are you a critical access hospital?

Do you bill under the hospital tax ID? If you're billing under the hospital tax ID on a UB-04, it is probably conflicting with the TC claim. In that case, perhaps there should be one claim with the global code. However, if the facility is a critical access hospital, there are special rules so you may want to get some input from other CAH billers.

The hospital is not Critical access. We just became an RHC (provider based type that is owned by a hospital) so we bill Medicare A only using the UB04. We do bill under the hospital Tax ID#. The Medicare rep told me to send a claim of ours without the modifier 26 which I did and it paid and so did the hospital claim TC so I thought that was right. However the RHC rep that trained us for a few hours said that removing the 26 modifier was not complaint & we have to bill professional component & not global. The RHC chapter guidelines from Medicare state similar info but not exact. So I didn’t want to just assume it was ok & get offsets on hundreds of claims later. Is there an article or rule that says we can bill the global instead of 26 if billing under the same tax I’d #?

 

[sls314]

The hospital is not Critical access. We just became an RHC (provider based type that is owned by a hospital) so we bill Medicare A only using the UB04. We do bill under the hospital Tax ID#. The Medicare rep told me to send a claim of ours without the modifier 26 which I did and it paid and so did the hospital claim TC so I thought that was right. However the RHC rep that trained us for a few hours said that removing the 26 modifier was not complaint & we have to bill professional component & not global. The RHC chapter guidelines from Medicare state similar info but not exact. So I didn’t want to just assume it was ok & get offsets on hundreds of claims later. Is there an article or rule that says we can bill the global instead of 26 if billing under the same tax I’d #?

Rural Health Clinics have a different set of rules and billing guidelines to follow - it's not my area of expertise. However, I looked at the Medicare Claims Processing Manual section for RHCs, and I'd be inclined to agree that you need to be billing with the 26 modifier to be compliant.

Since RHCs have unique guidelines, I'd suggest putting RHC in your thread title. It might help catch the attention of members who work in that setting and cut down on responses geared more toward other provider settings.

I think I absorbed the gist from reviewing the Medicare manual, but since I don't have firsthand experience billing for an RHC I'm hesitant to advise you on specifics. I'd hate to have misinterpreted something and given you bad advice.

I hope you find the answer you're looking for, so you can resolve your claims! Good luck!

 

[thomas7331]

The hospital is not Critical access. We just became an RHC (provider based type that is owned by a hospital) so we bill Medicare A only using the UB04. We do bill under the hospital Tax ID#. The Medicare rep told me to send a claim of ours without the modifier 26 which I did and it paid and so did the hospital claim TC so I thought that was right. However the RHC rep that trained us for a few hours said that removing the 26 modifier was not complaint & we have to bill professional component & not global. The RHC chapter guidelines from Medicare state similar info but not exact. So I didn’t want to just assume it was ok & get offsets on hundreds of claims later. Is there an article or rule that says we can bill the global instead of 26 if billing under the same tax I’d #?

Professional components of hospital services are almost never billed on a UB-04 form. If you are really a provider-based clinic of a hospital, then your physicians should be credentialed to bill Part B and would bill for those professional components, with modifier 26, on a CMS-1500 form. You'd use POS code 19 or 22, depending on whether the clinic is on-campus or off-campus. In the unlikely event that your carrier wants you to bill professional services on the UB-04 (although very few payers allow this), you'd distinguish the professional services from the technical by billing those charges with different revenue codes - you wouldn't bill a global charge on a single line. But as far as I know, an RHC and a provider-based clinic are two different things and an RHC cannot also be a provider-based clinic of a hospital - it's one or the other. An RHC is mainly for primary care in an underserved area and wouldn't be billing for reading of x-rays done in a hospital. I'm not an expert on RHC billing either, but by my understanding, RHCs do get a bundled payment rate that includes physician and facility services, but again, this is for primary care services, not for hospital services.

I think you need to get some guidance from your hospital management on this as it looks like you're getting conflicting information. Provider-based status and billing rules are complex and there are many criteria that have to be met in order to be eligible to bill this way. Your hospital leadership should be giving you clear instructions in a written policy on how to do this - this can't be a 'trial and error' to see what gets paid kind of thing and if not done correctly it could make a big mess.