When Do You Use a 26 Modifier?
I commonly get questions about when to use the TC and 26 modifier codes. It seems that there is some confusion about when to use each and, more often, when NOT to use them.
It is important to remember that modifiers in general are NOT to be used as
the rule but rather, the exception. The TC and 26 modifiers are no different. There are unique codes that when billed are considered to have payment bundled together for both the technical performance of the procedure/test as well as the professional interpretation of the information that procedure/test provides. So when a particular code is billed without a TC and 26 modifier, the payer assumes that the physician's office that is billing for that code is providing both the technical component (performing the test) and professional component (interpreting the test).
Let's define each modifier to look a little closer:
TC Modifier - The TC modifier would be used in the case that an outside physician ordered a test to be performed and that test was performed and the results sent to the ordering physician for interpretation. The clinic performing the test would append the TC modifier to the test when billing.
26 Modifier - The ordering physician would receive the raw data from the test and then interpret that data. The ordering and interpreting physician would then append the 26 modifier to the test when billing.
Perhaps some clinical scenarios of when to and when not to use these modifiers will help to solidify this concept:
Appropriate Use of these modifiers:
Let's say that Dr. A does not have an OCT in his practice so when he orders a retinal OCT he will sent the patient to Dr. B's office who has an OCT and will perform the test. Dr. B's office will perform the OCT and sent the data back to Dr. A for interpretation. The billing would look like this:
Dr. B's office would bill for a 92134-TC
Dr. A's office would bill for a 92134-26
Inappropriate Use of these modifiers:
Now let's say that Dr. A refers a patient to Dr. B for an evaluation of macular degeneration. In that evaluation Dr. B orders (and has her clinic perform) a macular OCT and she also bills for the 92134 with no modifiers. Then Dr. B sends Dr. A a letter and included in that letter is a copy of the OCT. If Dr. A evaluates that OCT for his own records and plan that is appropriate, but it WOULD NOT be appropriate for him to also bill a 92134-26, since Dr. B already performed that task.
Understanding the correct use of TC and 26 modifiers is key to filing clean claims and avoiding denials. Remember, the facility that performed the test must also file a claim for reimbursement of the technical component AND the doctor interpreting the test will bill the professional component. If they are one in the same, there is no need for a modifier.