Knowing when to bill globally and when to segment a code into the professional component (modifier 26) or the technical component (modifier TC) is crucial in order to properly bill all of the services rendered.
When a service is billed globally, the provider is reimbursed for the equipment, supplies, and technical support, as well as the interpretation of the results and the report.
However, if someone else performed the technical aspects of a service, and the provider only interpreted the results and wrote a report, modifier 26 is necessary to indicate that the provider should receive reimbursement only for the professional component. Similarly, the technical component, modifier TC, includes billing only for the equipment, supplies, technicians, and facility, but not the interpretation of the service.
Strictly following these modifier guidelines is essential to your bottom line, because reimbursement will be higher when a code is billed globally than when it's billed with modifier 26 or TC appended to it. Many specialties have codes that can be billed according to these guidelines, including the following: Radiology:
Most radiology codes, including ultrasounds, x-rays, CT scans, magnetic resonance angiography, and MRIs may be billed with modifier 26 or TC, or with no modifier at all, indicating that the provider performed both the professional and technical services.
For example, an orthopedic surgeon sees a patient in his or her office for a broken ankle. The surgeon requests that x-rays of the patient's ankle be taken in his office. The surgeon would bill 73600, radiologic examination, two views.
Because no modifiers are appended to the code, the surgeon is indicating to the third-party payer that he or she performed both the technical component and the reading and interpretation of the x-rays for this patient.
If the x-ray were taken elsewhere, such as in a hospital, the hospital would bill the code 73600-TC, indicating that the hospital is billing only for the technical component. The radiologist at the hospital who read the x-ray would also bill the code 73600-26, indicating that he or she read and interpreted the x-ray and wrote a report concerning his or her findings. Pathology:
A pathologist may perform a gross and microscopic examination of an ovary, code 88305, during a surgery in a hospital. Under the circumstance that this pathologist bills independently, the hospital would bill the technical component 88305-TC, and the pathologist would bill for just services using the code 88305-26, billing for just the interpretation and the pathology report. Obstetrics:
A prime example of an obstetric code that may require modifiers is 59025, a fetal nonstress test. If the provider only does the interpretation and writes a report of the results of the test, he or she would bill the service as 59025-26, fetal nonstress test, interpretation and report only.
This probably would occur if the test is performed in the hospital, either inpatient or outpatient, and the hospital bills 59025-TC, indicating that it is billing only for the technical component. However, when the provider renders both the interpretation and the technical part of the service, usually in the provider's office, the fetal nonstress test would not need any modifiers and be billed just as 59025. Cardiology:
An example of the use of the modifiers 26 and TC when billing a cardiology code would be 93303, transthoracic echocardiography for congenital cardiac anomalies, complete. In this case, the provider would bill this code with a modifier 26, 93303-26, specifying that the only services that he or she provided were the interpretation and the report. The technical portion would be billed by the hospital as 93303-TC. Exceptions to the rules
There are some exceptions to the modifier TC and 26 rules, and the codes that fall under these exceptions should be billed by individual code indicating whether the code is for the professional or technical component or whether the code is a global code. For example, when code 93000, EKG, is used, this explains that the provider rendered the service of a routine EKG with at least 12 leads with interpretation and report.
For example, if Mrs. Smith sees her cardiologist for a routine visit, and an EKG is done in the office with interpretation and a report by the provider, code 93000 would be billed. However, if the patient has the EKG performed in the outpatient department of a hospital, and the readings are sent to her provider, then the hospital would bill 93005, tracing only without interpretation and report, and the provider would bill 93010, interpretation and report only. Rather than adding a modifier, each situation requires its own unique code.
Another exception to the professional and technical component modifier rule is the code 59400, routine obstetric care, including antepartum care, vaginal delivery, and postpartum care. The provider would bill the global code, 59400, which indicates that he or she has provided all of the prenatal visits and is including seeing the patient for her postpartum visit.
However, if the provider has not provided the prenatal visits and just delivers the baby, he or she would bill 59409, vaginal delivery only. In some instances, the third-party payer requires that each individual prenatal visit and postpartum visit be billed separately. In this case, the delivery would be billed as delivery only, 59409, and the prenatal and postpartum visits would be billed individually. If the provider performs just the vaginal delivery and postpartum care, then the service would be billed 59410, vaginal delivery, including postpartum care, and only the prenatal visits would be billed separately.
The guidelines for billing for deliveries would also apply to the other delivery codes.
For example, the global code for routine obstetric care, cesarean delivery, including antepartum care and postpartum care, would be 59510.
If a C-section only were performed, the code would be 59514, and if applicable, the prenatal visits and the postpartum visits would be billed individually.
If the C-section is billed including the postpartum care, the code would be 59515, and only the prenatal visits would be billed individually.
Ruth Dolby is president of Dolby Healthcare Consultants, LLC, in Stoughton, MA. She has 25 years of experience in healthcare and is a coding and compliance consultant for physician practices and other providers. She may be reached at email@example.com