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To bill for diagnostic tests, understand these three modifiers
The final part of this three-part series on modifiers concentrates on the components used for diagnostic reimbursement.
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Let’s see how you make out on this little quiz.
Answer the following questions true or false. The answers are given at the end of the article.
1. The TC modifier is used only when a technician performs a diagnostic test.
2. All diagnostic tests are considered bilateral by Medicare because there are two eyes.
3. A patient gets tired in the middle of a visual field examination, and the other eye is not tested. You are correct in billing the CPT global procedure code 92083.
Didn’t do so well? Read on.
Fee Components
Usually Medicare does not require a modifier when a diagnostic test is performed on the same day as an office visit or consultation; however, this varies with each contractor. Some have required modifier 25 be appended to the office encounter. As the consolidation from many independent Medicare carriers to fewer and larger Medicare Administrative Contractors occurs, an attempt at providing homogeneity is at work.
The global fee for a diagnostic test is most often composed of a professional component and a technical component. Essentially, the professional component consists of the physician work, namely, the interpretation and report. The technical component encompasses the expense of the equipment purchase/lease and maintenance, including technician salary if a technician is performing the test. It is not solely for compensating the technician, as many have erroneously interpreted.
Diagnostic tests modifiers
 Riva Lee Asbell |
There are basically three modifiers that are used in conjunction with billing for diagnostic tests: modifiers 26, TC and 52 (Table 1). In general, most ophthalmic diagnostic tests have a professional and technical component, and the reimbursement portion for each is found in the Medicare Physician Fee Schedule Database (MPFSDB) at www.cms.hhs.gov/PhysicianFeeSched/01_Overview.asp#TopOfPage.
However, there are a few ophthalmic diagnostic tests that are considered only a physician service and are not divided into a professional and technical component. It is assumed that these tests are performed solely by the physician. They are indicated in the MPFSDB by a 0 in the PC/TC column. Among these are extended ophthalmoscopy and gonioscopy. A complete list is provided in Table 2.
Modifiers 26 and TC. Placing modifier 26 after the CPT procedure code indicates that only the professional component is being billed. Placing modifier TC after the CPT procedure code indicates that only the technical component is being billed. Thus, if only the interpretation and report is performed, then append modifier 26 to the claim entry; if only the test itself is performed and there is no interpretation and report, append modifier TC.
Here are some clinical examples in which modifier 26 should be used:
- Reading fluorescein angiography without actually having performed the test in the practice.
- You practice in an office building with several ophthalmology practices. Your fundus photo camera is not working, and your colleague’s office agrees to perform the tests for you and send them to you for interpretation and report. Because you do not own/lease the equipment and do not incur the overhead expenses, you cannot bill the global fee – you must append modifier 26.
Here are some clinical examples in which modifier TC should be used:
- Performing fundus photos and not providing the interpretation and report.
- A patient is referred to the practice for visual field testing because the machine of the optometrist down the street is broken. The optometrist does not want you to do the interpretation and report – just send the printouts back to the optometrist. If you only perform the test and do not do the interpretation and report, you must append modifier TC to the CPT procedure code.
Ophthalmic ultrasound and biometry by partial coherence interferometry. Ophthalmic ultrasound with intraocular lens calculation (CPT code 76519) is a special case example wherein the professional component is considered a unilateral code and the technical component is a bilateral code. This is also true for ophthalmic biometry by partial coherence interferometry (CPT code 92136). (See modifier 52 for explanation of unilateral and bilateral code differentiation for payment.)
For those of you who may not have mastered this yet, here are some clinical scenarios with proper coding. This applies to both codes.
Example 1: A patient is examined and found to have a mature cataract in the right eye and surgery is scheduled. There is no significant problem in the left eye. The correct coding would be 76519 RT.
Many physicians like to have measurements on both eyes, but in the absence of medical necessity for performing the test, it would not be correct to bill the second side at this time. The code billed is the global one and includes both the professional and technical components.
Example 2: A patient is found to have bilateral cataracts that need to be operated on, and the decision is made to do surgery on both eyes, with the right eye being scheduled first. The correct coding would be 76519-26-50 and 76519-TC.
Reimbursement would be two times the allowable for 76519-26 and once for 76519-TC.
Example 3: The patient in example 1 returns 6 months later and decides that she wants surgery for the left eye. Measurements had been taken initially, but only the right side was billed. It would now be appropriate to bill for the left side. The correct coding would be 76519-26-LT
The physician is entitled to payment for the professional component again for the left side, but already has been paid for the technical component in the global fee.
If the patient returns after 1 year for the second eye, then the global fee may be billed again.
Modifier 52. The use of this modifier is connected to the issue of whether a given diagnostic test is considered unilateral or bilateral by Medicare. Unilateral tests are those that have each eye paid separately for the test, whereas bilateral tests are those in which the fee encompasses payment for both sides. This information is published in the MPFSDB.
Modifier 52 is the reduced services modifier and should be used when a diagnostic test designated as having the bilateral surgery indicator of 2 in the MPFSDB (the fee is based on the performance of the test on both sides) is only performed on one eye. Current examples of this include CPT code 92250, fundus photography when performed only on one eye; CPT code 92020, gonioscopy when performed only on one eye; and CPT code 76514, pachymetry when performed only on one eye.
Examples requiring application of modifier 52 include:
The patient gets tired in middle of visual field, and only one side is tested.
The patient is anophthalmic, and fundus photos are taken of the one eye.
Pachymetry is performed only on one eye because the fellow eye is phthisical.
Conclusion
This concludes this three-part series on modifiers. Granted, mastering them may be tedious; however, if you want to be sure of optimizing your reimbursement and remaining in compliance with Medicare, it is mandatory.
Quiz: All answers are false.
- CPT codes, copyright 2008, American Medical Association.
- Riva Lee Asbell can be reached at www.rivaleeasbell.com.