This modifier indicates "professional component"
Our pathology group is a private practice, not part of the hospital where we perform our services. Our new biller maintains that since we're an independent entity, it's not necessary to use any modifiers when billing our services. But we've experienced massive daims rejections recently. Could this be due to the fade of modifier use? If so, should our new biller have anticipated this?
Yes on both counts. If your billing service is reporting place of service 21 (inpatient hospital) or 22 (outpatient hospital) and you're performing your services in a hospital-owned lab, modifier -26 (professional component) should be used unless the CPT code in question describes the professional component alone. Since the hospital owns the lab, it is billing the technical component of the service, something your billing service should have known.
Reimbursement for an EP consult
Our large cardiology group encompasses numerous subspeda/ties, invasive and noninvasive cardiology and cardiac electrophysiology among them. When one of our general cardiologists refers a patient to our cardiac EP, who sees the patient on the same day, our claims are often rejected. Both the generalist's visit and the EP consult are typically paid on appeal, but we'd like to avoid having to file an appeal. What's happening, and what do you suggest?
One possibility is that the claims-from the same EIN and for the same day-are seen as bundled E&M services. Another is that the insurer doesn't recognize electrophysiology as a distinct subspecialty.
Arrange a meeting with the provider relations staff of the third-party payers who reject such claims and discuss ways to get paid on the first try. Provide Medicare's rule on payment of consultations for different specialties within the same practice, and offer to add a modifier or other mechanism that will alert the insurer to the need to pay for both services. …