Modifier 26: Appropriate Use
Modifier 26: Professional Component
The total service/procedure described by a single CPT code is comprised of two distinct portions: a professional component (modifier 26) and a technical component (modifier TC). The professional component of a diagnostic service/procedure is provided by the physician and may include supervision, interpretation, and a written report. The technical component of a diagnostic service/procedure accounts for equipment, supplies, and clinical staff (such as technicians). Fees for the technical component generally are reimbursed to the facility or practice that provides or pays for the equipment, supplies, and/or clinical staff.
To identify professional services only for a service/procedure that includes both professional and technical components, append modifier 26 Professional component to the appropriate CPT code. Note that this modifier is appropriate when the physician supervises and/or interprets a diagnostic test, even if he or she does not perform the test personally. Do not append modifier 26 if there is a dedicated code to describe only the professional/physician component of a given service (e.g., 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).
Correct Use of Modifier 26
When using the 26 modifier, you must enter it in the first modifier field on your claim. Understanding the correct and appropriate use of this modifier will be key to filing clean claims and avoiding denials for duplicate billing. The following examples of modifier 26 in use will help us understand how to correctly define and report a physician’s professional component.
- A sleep center performs polysomnography for a patient. A physician not associated with the sleep center facility interprets the findings of the test. This physician would append modifier 26 to 95811 to represent her interpretation of the polysomnography.
- A pregnant patient presents to the ER with premature contractions. The ultrasound performed in the hospital detects abnormalities in the pregnancy. The patient is referred to a specialist for follow up, and the hospital imaging report is sent with the patient for further review. The specialist reviews and interprets the ER ultrasound, so the specialist would use modifier 26 on the ultrasound CPT to represent their interpretation-only service of the report.
- A treating physician orders a test from an outside laboratory for his patient. The lab’s pathologist then provides its written interpretation to the attending physician. In this case, the pathologist could bill the procedure 83020 with a modifier 26 representing their interpretation of the test.
To illustrate incorrect use, the treating physician in the example above cannot bill 83020- 26 themselves after they review the pathology report, because the pathologist has already interpreted the test. The treating physician can include his own interpretation in his medical decision-making, but should not bill separately for it. More examples of incorrect use are as follows:
- Reporting it for re-read results of an interpretation provided by another physician
- Do not append to Technical only procedure codes, Example: CPT 93005
- Do not append to Global test only codes, Example: CPT 93000
- Do not append Modifier 26 to Professional component only codes. An example of a professional component only code is 93010, Electrocardiogram; interpretation, and report. Modifiers 26 cannot be used with these codes.
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