Procedure Coding: When to Use the Modifier 26
This is part of the Modifier Series, the articles include:
The 26 modifier is a particularly unique coding tool in the billing and coding world. As we know, a modifier explains to payers the specific work that was done by a physician during the treatment of a patient. This concept is taken a step further when modifier 26 is needed. This is because modifier 26 can only be used for certain kinds of procedures which include a “professional component”. For this reason, knowing when to appropriately use the 26 modifier frequently causes confusion among billers.
In order to help dispel some of the confusion, this article will explore some of the most common uses of modifier 26, and discuss the requirements of when and how to utilize it correctly.
DEFINING MODIFIER 26
In procedure coding, you’ll find that there are certain procedures that are a combination of a professional component and a technical component. Most often, you’ll see this among diagnostic testing procedures such as ultrasounds or CT scans. When the professional component of one such procedure is performed separately, the specific service performed by the physician may be identified by adding the modifier 26. Let’s break that down a little further.
“Professional component” is outlined as a physician’s service which may include supervision, interpretation, or a written report, without having performed the test. In short, modifier 26 in its correct use reports that a physician’s service was to interpret the results of a test when they didn’t personally perform it. Wondering when would this type of scenario occur? The following examples of modifier 26 in use will help us understand how to correctly define and report a physician’s professional component.
Examples of when to use modifier 26:
- 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 their 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.
Incorrect use of the 26 modifier:
- 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 her own interpretation in her medical decision-making, but should not bill separately for it.
Understanding the correct and appropriate use of modifier 26 will be key to filing clean claims and avoiding denials for duplicate billing. Remember, the facility that performed the test must also file a claim for reimbursement of the technical component. This is why reporting modifier 26 on the same procedure code for the interpreting doctor will be critical in demonstrating your provider’s specific role in the service performed. As such, reporting the 26 modifier correctly decreases your likelihood of incorrect payer denials and reduces delayed payment.
It can be easy to become confused trying to keep the components of a procedure straight and remembering when modifier 26 should be applied. A helpful tip to keep in mind is this: if the provider doesn’t own the technical equipment, they can’t bill for the technical component. In order to bill correctly, the use of modifier 26 conveys that the provider only performed the professional component of the procedure.