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modifer 26

  1. #1
    Question modifer 26
    Medical Coding Books
    when my providers do an ultrasound in the office (we are an outpt hospital setting) do we use the mod 26. We have been paid both ways per the biller with the 26 and without the 26. The provider does the entire procedure. He reads and performs the ultrasound himself. (Ultrasounds he does are: neck,arm,breast)

    We just want to know the correct way.

    thanks so much

  2. #2
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    The big question is - does your provider own the equipment? If he owns it, performs the procedure and interprets then you don't need -26.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Default
    The reimbursment is going to be different with and without a -26. In some instances, I cant get paid for the taking and reading the US, so I will resumbit with a -26 and atleast get something.
    Jennifer

  4. #4
    Location
    Omaha, Nebraska
    Posts
    144
    Default Insurance Background
    I was in the insurance business for ~ 18 years ... it didn't matter whether or not the provider "owned" the equipment - if the U/S tech "physically" performs the U/S and is employed by the physician's office AND the physician "personally" reads & interprets the U/S - then the service should be billed as a TOTAL component (i.e. no modifier needed) ... you should be getting reimbursed for the TOTAL component. If you are not - you need to be going back to the payer and ask why ....

    P.S. from an insurance company standpoint, yes - reimbursement will be different based on what portion you are billing for (i.e. TOTAL, TECHNICAL or PROFESSIONAL). You should be billing just one line item for the TOTAL component ... for example: an ultrasound of the abdomen, 76700 - would be billed:

    TOTAL: 11/20/08 11 76700 001 $300.00

    TECHNICAL Only (meaning all you did was PERFORM the U/S): 11/20/08 11 76700-TC 001 $200.00

    PROFESSIONAL Only (meaning all you did was INTERPRET the results): 11/20/08 11 76700-26 001 $100.00

    Hope this makes sense!
    Last edited by ckkohler; 11-20-2008 at 11:47 AM.

  5. #5
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    Quote Originally Posted by ckkohler View Post
    I was in the insurance business for ~ 18 years ... it didn't matter whether or not the provider "owned" the equipment - if the U/S tech "physically" performs the U/S and is employed by the physician's office AND the physician "personally" reads & interprets the U/S - then the service should be billed as a TOTAL component (i.e. no modifier needed) ... you should be getting reimbursed for the TOTAL component. If you are not - you need to be going back to the payer and ask why ....

    Sorry Ckkohler---insurance business or no insurance business, that is NOT PROPER CODING!!

    If you OWN (rent/lease) the equipment and read the films--no modifier is necessary, you get the total component.

    If you are a facility(hospital, ASC) --you own the equipment, you use the TC Modifier

    If you are a practioner reading and supervising at a facility other than your office- you use the 26 Modifier.

  6. #6
    Location
    Omaha, Nebraska
    Posts
    144
    Default
    mbort - I do not believe there was any reason for you to treat me like that! No need to get snide and use RED coding ... no reason to make an issue of the insurance or no insurance. Regarding OWNING the equipment - I only meant as an insurance company - we didn't question who owned the equipment. Actually - what you were saying was the same as what I was saying. I think we all need to remember - this is a forum for LEARNING.

    I will be very careful to whom and how I respond in the future. Thanks for upsetting me.

  7. #7
    Location
    ENGLEWOOD/DENVER
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    2,338
    Default
    Quote Originally Posted by ckkohler View Post
    mbort - I do not believe there was any reason for you to treat me like that! No need to get snide and use RED coding ... no reason to make an issue of the insurance or no insurance. Regarding OWNING the equipment - I only meant as an insurance company - we didn't question who owned the equipment. Actually - what you were saying was the same as what I was saying. I think we all need to remember - this is a forum for LEARNING.

    I will be very careful to whom and how I respond in the future. Thanks for upsetting me.
    ckkohler--I apoligize that you took my message personally. I was mearly stating that it was improper coding.

    I felt that your statement "I was in the insurance business for ~ 18 years ... it didn't matter whether or not the provider "owned" the equipment" was incorrect and that proper coding should be addressed. Because you worked for an insurance carrier that allowed that type of practice does not warrant support of such practice, because it does matter who owns the equipment.

    The message was not intended to offend you, it was to educate the proper coding techniques for the modifier usage that was in question.

  8. #8
    Location
    Omaha, Nebraska
    Posts
    144
    Default
    Like I said - I understood the forums to be teaching & learning opportunities; and as such we should treat one with a little more understanding. Let me clarify my position as I do not understand what you mean by "allowing that kind of practice" ... from a reimbursement standpoint - and that is what we are concerned with, I think ... if a provider did the entire package ... they PERFORM the ultrasound and they READ/INTERPRET the ultrasound - they should bill the total component without any modifier.

    I believe that was the question that was being asked and answered.
    Last edited by ckkohler; 11-20-2008 at 01:10 PM.

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