Wiki Question on Modifer 26 Professional Component

[ronaldgfell]

Getting close to finishing the CPC coding course, I have a question if anyone can help?


My thinking after all the reading is that if a doctor sends a sample (s) out for consultation to a pathologist, when the pathologist reports his findings, that is a "professional component" and should be reported as say 88323-26 (consultation and report on referred material requiring preparation of slides)....

If the pathologist works at the lab....doesnt he still provide a professional component if the materials are sent to him, note drawn in his working lab???

If the materials are drawn in the lab where the pathologist works, and he sends the doctor a required report, should he not be billing for the global component which includes the technical and the professional component....

If not when would the pathologist EVER bill the 26 modifier?????????????

I thought that in standard billing, the facility can bill for both the technical and professional components and reimburses the pathologist /pathology group for the professional component per their mutual agreements.

And under full fee billing Physicians bill for both the professional and the technical components and subsequently reimburse the facility for the technical component according to their mutual agreement????

Please give me some way to BETTER UNDERSTAND WHEN A PROFESSIONAL COMPONENT IS USED AND WHEN A TECHNICAL COMPONENT IS USED...

Thanks
Ron

 

[Lujanwj]

The way I like to think about it is "who owns the equipment (TC)" and "who's interpreting the data(26)". It's a way to split the code so the person/facility that owns the equipment gets paid for the machine and the person the does the interpreting get their share. Remember if you own the machine and do the interpreting you don't need to modify the code. One caveat to this is if done at a facility they might have a contract with the Dr that only the facility can do the interpretation. That will means that the Dr will not code a radiology code at all and going over the results/interpretation will fall under Medical Decision Making of an E/M.

Example
Patient comes into Dr office with a broken wrist. Dr does 2 views of the wrist, writes a report/interpretation of the images and owns the Equipment (x-ray machine). In this case you would code 73100 with no modifiers because Dr owns the equipment and does the interpreting.

Example
Dr sees patient at the Facility with a broken wrist and gets 2 views of the wrist and writes a report (interpretation) of the images. In this case you would code 73100-26 for your Dr because your Dr only did the interpretation and the Facility would code 73100-TC because they owned the equipment.

To answer you pathology question (which I don't deal with so my knowledge is based on logic), if blood was sent to the pathologist at a lab they run the test and do the interpretation they will code it without a modifier. At that point the results/interpretation will be sent to the Dr where it will become part of the Dr's Medical Decision Making of their Evaluation and Management.

With regards to Facility and the lab, depends on if the facility owns the lab, or does the have an outsourcing to a lab with a contract and what's in the contract. Can't really answer that.

I hope this helps.