Fighting Fraud

The Low-down on Modifier 26

Know the basics to keep the OIG from knocking on your door.

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When the Office of Inspector General (OIG) released its 2010 work plan, one of the hot ticket items was emergency department (ED) imaging services, which involve the use of Modifier 26. According to the work plan, in 2007, Medicare reimbursed physicians approximately $207 million for imaging interpretations in EDs, which was a red flag for the OIG and is now under major scrutiny.

The OIG has set forth to "review a sample of Medicare Part B paid claims and medical records for diagnostic X-rays performed in hospital emergency departments to determine medical necessity in conjunction with the appropriateness of payments."

The OIG Work Plan is a yearly plan that details issues from the Office of Audit Services, Office of Evaluations and Inspections, Office of Investigations, Office of Counsel to the Inspector General, Office of Management and Policy and Immediate Office of the Inspector General. They put forth the issues that will be addressed during each fiscal year.

Know the Work Plan
It is of vital importance for a coder to be aware of what is on the OIG work plan each year and how it may affect his/her practice or facility if there are any deficiencies. I strongly suggest a careful review and audit of some sample claims of those services performed within your practice. There is no way of knowing if your practice is on the OIG's radar, but it is in your best interest to take the pulse of your practice to ensure it is maintaining compliance in these areas.

In a Nutshell
Modifier 26 is the Professional component and the TC modifier is the Technical component. If you forget to apply modifier 26 on your claim when the provider renders the service in a facility setting, you could be looking down the barrel of some serious double-billing accusations.

The TC modifier is for the entity that owns the equipment and the 26 is for the professional interpretation.

To properly code for modifier 26, the physician who is utilizing it must indicate in his notes that he interpreted the findings and wrote the report. Only use modifier 26 with procedures that are either 100 percent technical or 100 percent professional. Meaning, it should only be used for procedures having both components.

How CMS Defines This:
Modifier -TC should not be used if there is a specific code that describes a procedure that is 100 percent technical (has no professional component). For example, it would be inappropriate to use modifier -TC in conjunction with CPT code 93005 (electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report).

-26 Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier -26 to the usual procedure code.

Use modifier 26 when a physician interprets but does not perform the test. Modifier -26 should not be used if there is a specific code that already describes only the physician component of a given service. For example, it would be inappropriate to use modifier -26 in conjunction with procedure 93010 (electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) because it is 100 percent professional.

The American College of Emergency Physicians (ACEP) had this to say:

FAQ

How do I document my x-ray interpretation to be reimbursed for Medicare?

A

An emergency physician may bill for the interpretation and report of an X-ray for a Medicare patient when a "complete written report similar to that prepared by a specialist in the field" is documented. CMS has not identified a specific documentation standard but states that the physician must include relevant clinical issues, comparative data, and study findings. To these three categories, the American College of Radiology Standard for Communication, Diagnostic Radiology has suggested the addition of a description of the procedure and materials, any limitations, and clinical impression, conclusion, or diagnosis. CMS has not expressly adopted these specific suggestions.

A separate written report, although a fully distinct document, is not required by CMS. However, some Medicare carriers have independently established more restrictive criteria.

FAQ

Are there situations in which both the emergency physician and the radiologist can get paid for an interpretation?

A

A basic CPT principle is that "any procedure or service...can be rendered by any qualified physician." CPT addresses how a single provider (i.e., the same physician or a physician of the same specialty working for the same medical group) can code for services provided in a patient encounter. CPT does not expressly address how different providers can code for services they respectively provide for a patient encounter. Under CPT, if a provider appropriately provides a service to a patient, the provider may code for it.

Payers, however, may establish payment policies that modify CPT principles. For example, under Medicare payment to both physicians is rare and will be made only when the knowledge and expertise of the second physician is presumed to be above and beyond that of the first, and if the second physician contributes substantially to the X-ray interpretation. The expertise of the second physician must also be medically necessary. Some carriers require that a -77 modifier (Repeat Procedure by Another Physician) be used when both physicians bill. Of course, this requires that the respective physicians somehow know that the other is submitting a claim.


FAQ

If I bill for an ECG or X-ray interpretation, can I also count this service (assign a point) in the Evaluation and Management Medical Decision-Making (MDM) value as listed on the MDM table in the CMS distributed Marshfield Clinic tool for review of images/tracings?

A.

On a basic level--there is the potential for 3 "points" in the CMS-suggested Medical Decision Making (MDM) audit scoring in the area of Amount And/ Or Complexity of Data to Be Reviewed for radiology/cardiology/lab and other diagnostic services. One point is assigned for ordering the study and using the results for patient evaluation/management. Two points are available for the direct visualization of the tracing/film/specimen.

 It is possible to give credit for the single point assigned for ordering of the study in addition to billing for the interpretation of the test. It is the latter 2 points that raise some question and are discussed in this scenario.

 The discussion revolves around the fine point of whether the complexity of data to be reviewed is an assessment of service separate from the work of the interpretation of the test. If these are separate, then the 2 points can be given in addition to billing for the interpretation of the test.

CPT addresses this issue by noting that the interpretation of diagnostic tests is not included in the levels of E&M services. On the other hand, Medicare seems to differentiate between a "report" and a "review" in respect of billing and getting credit under the complexity of data section of the MDM. In that there is no specific clarification on this issue and payment policies do differ, you are advised to contact your local carrier for advice. For more information, please click on the following link: http://acep.org/practres.aspx?id=30504


Check with your local fiscal intermediary (FI) and your commercial carriers to see what their policy is when utilizing Modifer 26 for your claims. I strongly suggest you conduct a baseline audit of these services to ensure compliance, as you do not want to be an outlier and end up on the wrong end of an audit by the OIG.

Next month I will discuss critical care services and compliance with CMS.

Holly Cassano has been a certified professional coder for more than 3 years and involved in practice management, coding, auditing, teaching and consulting for multiple specialties for the past 13 years. She served two terms as an AAPC Local Chapter Officer and has written several articles. She is currently the coder and physician educator for the emergency room physicians at the Cleveland Clinic Florida. You can reach her at hjcpmg@yahoo.com.


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