Appropriate Use of Modifier 26

Modifier 26

Generally, Modifier 26 is appended to a procedure code to indicate that the service provided was the reading and interpreting of the results of a diagnostic and/or laboratory service.

To help ensure the accurate adjudication of claims, we ask that you adhere to the following Modifier 26 guidelines.

Modifier 26 is only appropriate in one of the following places of service (POS):

• Hospital inpatient (POS 21)
• Hospital outpatient (POS 22)
• Emergency Room (POS 23)
• Off Campus-Outpatient Hospital (POS 19)

Use of Modifier 26 is not appropriate in conjunction with any other place of service code.

Modifier 26 is not appropriate when:

• The same provider performs both the technical and professional components (unless the same provider reports both components and the technical portion is purchased).
• Reporting re-read results of an interpretation provided by another physician.
• Appended to claims that include:
  • Technical-only procedure codes.
  • Global-test only codes.
• Claims submitted with Modifier 26 that are billed in conjunction with the global component will not be reimbursed.

Example use of Modifier 26

A patient seeks treatment at the Emergency Room (ER) of a hospital for a head injury. The facility performs a CT of the head without contrast (CPT® Code 70450). The film is sent by courier to a noted local radiologist’s office for review. The radiologist reads/interprets the CT film and seeing no sign of injury or damage calls the hospital’s ER and advises them to release the patient.

The facility will submit a claim for providing the technical component of the service with the following claim elements:

• CPT Code 70450
• Modifier TC (to indicate the technical component)
• POS 23

The radiologist will submit a claim for the reading and interpreting of the results (the professional component PC) of that diagnostic service with the following claim elements:

• CPT Code 70450
• Modifier 26
• POS 23

The place of service indicated on the radiologist’s claim, in this case, reflects the location where the CT was performed, not the location where the radiologist actually reviewed the film. If the radiologist indicated a place of service of 11 (office), the service 70450 appended with Modifier 26 would be denied for an ineligible place of service.

Please note the above also applies to the technical component (TC). Only POS 21, 22 and 23 are appropriate for TC and PC component. If services are rendered in a freestanding radiology/imaging center then the center would bill globally.

In addition, if a specialty physician is over-reading or interpreting the procedure as a consultation in the office (POS 11) the service will not be reimbursed separately from the global component.

POS 11 is not recognized separately in the outpatient setting.

The procedure must be billed globally which would include the physician component.

Cardiologist performs and interprets echocardiography in the office then appropriate code should be billed globally: 93306 with POS 11 global components.

Note: If cardiologist is interpreting for the hospital then the POS would be 21, 22 or 23.