|
Reporting
modifiers 26 (Professional component) and TC (Technical
component)
may seem a breeze, but if you forget to apply modifier 26 on your claim
when
the cardiologist renders the service in a facility setting, you could
be
setting yourself up for serious double-billing accusations.
Problem: Coders “don’t split up the
technical
and professional components,” says Angela Cook, patient
accounts manager
with a physician institute in Lecanto, Fla.
Brush up
on
your professional, technical component modifier skills and learn what
to do
when your cardiology practice purchases modifier TC.
Draw the
Line Between Modifiers
Certain
CPT
codes, such as those for myocardial perfusion studies (78465, Myocardial
perfusion imaging; tomographic [SPECT], multiple studies [including
attenuation
correction when performed], at rest and/or stress [exercise and/or
pharmacologic] and redistribution and/or rest injection, with or
without
quantification), consist of two components: the technical component
(modifier TC) and the professional component (modifier 26).
In other
words: “TC
is for the
entity that owns the equipment,” says Peggy Stilley, CPC,
office manager
for an Oklahoma University-based private physician practice in Tulsa,
“and the
26 is for the professional interpretation.”
Break Down
Modifier 26
If your
cardiologist performs a myocardial perfusion study with a facility’s
equipment,
you should use 78465 and append modifier 26 to reflect that he
interpreted the
findings and wrote the report.
Keep in
mind: You
should not
use modifier 26 with procedures that are either 100 percent technical
or 100
percent professional. You should use it only on procedures having both
components.
For
example,
if a doctor performs an ECG in the office setting, he would report his
service
with 93000 (Electrocardiogram, routine ECG with at least 12 leads;
with
interpretation and report). If the physician interprets the same test
in the
hospital, he should report it with 93010 (... interpretation and report
only).
The first code is a complete service code while the second is limited
to the
physician’s interpretation.
Warning: If the physician fails to
append
modifier 26 and the facility nonetheless bills with modifier TC, the
technical
portion of the service will have been double-billed, which could lead
to
accusations of fraud or a demand for repayment, says Laureen
Jandroep, OTR,
CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN
Institute,
an online coding certification training center based in Absecon, N.J.
Safeguard: Medicare will not pay a
physician for
the technical component of services provided in a facility setting. In
other
words, if your claim lists a place of service (POS) as an outpatient
hospital
(POS 22), this will prevent double-billing from happening.
Tackle
Modifier TC
In the
same
scenario above, the facility owning the equipment would then report the
myocardial perfusion study code 78465 using modifier TC for its portion
of the
test. Modifier TC indicates to the payer that the facility supplied
only the
technical component and not the professional interpretation, says Marvel
Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.
What to Do
When MD Reports Both Components
If the
cardiologist performs both technical and professional components, he
should
submit a CMS-1500 form with the CPT code and no modifier to indicate he
provided the global procedure, Hammer says.
For
example,
a cardiologist orders a myocardial perfusion study and interprets and
documents
the findings. He owns or leases the equipment involved and employs a
nuclear
tech. In this scenario, the cardiologist performed the global procedure
and
would submit the CMS-1500 with code 78465. He will be reimbursed for
the entire
global relative value unit (RVU) amount.
According
to
Regence BlueCross BlueShield of Oregon, “A ‘complete’ procedure (that
is,
professional plus technical component) billed with no modifier attached
to the
procedure code, is only eligible for reporting and reimbursement when
that
provider owns the equipment and is also providing the professional
component.”
You Can
Purchase Modifier TC
But
suppose
that your cardiologist does not have the capability to perform a
myocardial
perfusion study (or other diagnostic test) in his office. Instead, he
contracts
with another physician, medical group, or supplier, such as a mobile
imaging
lab, to perform the technical component for him.
A provider
that does not own the diagnostic equipment or employ the necessary
staff may
purchase technical and/or professional components from another supplier
and
potentially receive reimbursement for the global code, Hammer says.
The
Medicare
Claims Manual 100-04, Chapter 1, 30.2.9, Payment to Physician for
Purchased
Diagnostic Tests -- Claims Submitted to Carriers, states, “A physician
or
medical group may submit the claim and (if assignment is accepted)
receive the
Part B payment, for the technical component of diagnostic tests which
the
physician or group purchases from an independent physician, medical
group, or
supplier.”
Catch: When you purchase the
technical
component, you have to list the purchasing entity’s provider number.
That
means, you can deal only with a Medicare recognized entity.
Avoid 2
Purchased TC Pitfalls
According
to
MCM Part 3, you should not submit a global code on your claim when your
practice purchased one component of the service. You bill it as
split-billed.
In other words, you use modifier 26 for your own piece and bill the TC
as a
purchased modifier.
Pitfall
#1: Always
be sure to
indicate when you purchased the technical component. If you don’t
indicate that
you purchased it, you have a potential false claim.
According
to
Trailblazer Health, you may not submit a global code when your practice
purchases one component. You should submit the technical and
professional
components on separate lines or separate claims depending on how you
file them
so the carriers can determine payment jurisdiction and price services
correctly.
Reporting
your myocardial perfusion study code (78465) this way still means that
you’ll
be paid as if you reported the code without any modifiers. The
components
should add up to the same amount as if you had billed globally.
Pitfall
#2: If you
purchase
the technical component, you are not allowed to mark up the price. What
you
have to put down as the charge is the fee schedule amount or the actual
amount
you paid -- whatever is less.
Prior to
reporting for purchased test components, make sure to consult with your
attorney about other regulatory concerns before changing any practices.
|
