Tuesday, May 3, 2011

MODIFIERS SPECIFIC TO RADIOLOGY

26 Modifier (Professional Component)

When the physician component is reported separately, the 26 modifier must be added to the procedure code. The payment includes the physician’s work, practice expense and malpractice expense.

TC Modifier (Technical Component)

When the technical component is reported separately, the TC modifier must be added to the procedure code. The payment does not include any physician work Relative Value Units (RVUs). Refer to the section “Physician Supervision of Diagnostic Tests” for complete information on requirements for physician supervision for the technician who may actually perform the tests.

Repeat Radiological Procedures (Modifiers 76 and 77)

Radiologists should use the following modifiers when an X-ray procedure is being repeated on the same day:
76 Modifier Repeat procedure by same physician

The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the 76 modifier to the repeated procedure/service.

77 Modifier Repeat procedure by another physician

The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding the 77 modifier to the repeated procedure/service.
These modifiers will help Medicare identify that the services are not duplicate billing problems but medically necessary repeat procedures.

Please be aware that the second reading of the same X-ray is considered an over-read and is not a covered service under Medicare. Do not use a 76 or 77 modifier when billing for the second reading of an X-ray.

50 Modifier (Bilateral Procedures)

The 50 modifier is valid with certain diagnostic procedures and, when reported with those procedures, will be reimbursed at the full Medicare fee schedule for each site or organ or site of a paired physiological entity.

To obtain proper reimbursement for bilateral procedure, report a 50 modifier and a quantity of one. TrailBlazer will not process a quantity of more than one.



Radiology, Pathology and Laboratory

Modifiers are used to report both the professional and technical components for radiology, pathology and laboratory services. Professional component only or technical component only codes do not require Modifier 26 or TC.

Modifier rules are as follows:

• Use Modifier 26 when billing separately for the professional component of a service.

• Use Modifier TC when billing separately for the technical component of a service.

• Total component (global) billing does not require a modifier.

• To ensure prompt and correct payment for your services, always use the appropriate modifier.

When billing for diagnostic and therapeutic hospital-based physician services, you should only bill the professional component and such billing should be submitted on the CMS-1500 claim form. Blue Cross will not separately reimburse technical components associated with hospital inpatient and outpatient services. Reimbursement for these services are included in the hospital’s payment.

The technical and/or professional components for all radiology and other imaging services may be billed by the PHYSICIAN only if he/she actually renders the service. The PHYSICIAN may not bill Blue Cross for the technical and/or professional component of any diagnostic test or procedure, including but not limited to, X-rays, ultrasound, or other imaging services, computerized axial tomography or magnetic resonance imaging by utilizing another entity’s NPI. The referring provider may not receive compensation, directly or indirectly, from the provider who rendered the service.

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