Wiki When does Modifier -26 apply to CPT 93458 in a hospital setting?

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she803

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Hello everyone!
We work at a hospital where we've been receiving denials from insurance carriers that modifier -26 needs to be appended to CPT 93458 and associated codes due to cardiac catherization procedure performed in hospital setting for POS 21, 22, and 23 when performing percutaneous coronary intervention procedures.

However, the cardiac surgeon disagrees claiming that the -26 modifier should not be applied to CPT 93458 or associated codes due to major deduction in reimbursement for all of these procedures he performed.

We have reviewed many CMS guidelines for these cath procedures but more clarity is needed.

We need more clarification on guidelines for the above scenario preferably from experienced specialty coders in this field and/or coding auditors that modifier -26 should be appended to 93458 and associated procedures when performing percutaneous coronary intervention procedures in a hospital setting POS 21, 22, 23 as indicated by insurance carrier denials.

Your assistance is greatly appreciated!
 
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For any procedure that involves a professional and technical component, the technical component is paid to the organization that owns and maintains the equipment used. So any time one of these procedures is performed in a hospital, the physician can only bill for the professional component only because they're using the hospital's resources and equipment for the procedure. The hospital is required to be responsible for all of the technical resources and only the hospital can bill that portion. A physician must always use a modifier 26 for any procedure with the PC/TC when performed in a hospital.

Though of course every physician would like to be paid more for what they do, but they should understand that the higher reimbursement in compensation for the use of the equipment, supplies, drugs and facility staff time that is involved in the procedure, and they are not eligible to receive this when they do the work in a hospital setting.
 
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Agree with Thomas and Amy.

The 26 modifier doesn't reduce a physician's reimbursement - it IS the reimbursement for the physician's time and expertise. The TC is for everything else.

When a physician bills globally (no 26/TC modifier), they aren't getting paid more for their time and expertise.

The additional reimbursement is for all the overhead expenses - nursing, supplies, equipment, etc. In this case, the hospital is providing all of that, so the facility is reimbursed the TC rate.
 
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sls314 said:
Agree with Thomas and Amy.

The 26 modifier doesn't reduce a physician's reimbursement - it IS the reimbursement for the physician's time and expertise. The TC is for everything else.

When a physician bills globally (no 26/TC modifier), they aren't getting paid more for their time and expertise.

The additional reimbursement is for all the overhead expenses - nursing, supplies, equipment, etc. In this case, the hospital is providing all of that, so the facility is reimbursed the TC rate.
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Great explanation.
 
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