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Pulmonology Coding Alert

Reader Question:

All Sides Must Understand Modifier 26, TC Rules

Question: In your article last month entitled "Can You Answer This Modifier Question? Your Spirometry Claims May Rely on It," you mentioned that if the office is in a private office setting (place of service 11) and the practice owns the machine, employs the technician, and the physician does the interpretation, you'll report 94010 without any modifiers, but if the pulmonologist interprets spirometries elsewhere and that facility owns the equipment, we should append modifier 26 to the pulmonologist's interpretation and the hospital will append modifier TC and submit a charge for 94010-TC.

My question is, we've had experiences where the other entity does not add the modifier TC to the claim. Then the payer reimburses them for the whole charge and we get denied for our modifier 26 charge. What can we do in these situations? Subscriber

Answer: Unfortunately, this is a common issue, according to Part B payer Novitas Solutions. Each month, Novitas receives "a significant number" of reopening requests asking the payer to add a modifier such as 26 or TC to particular services so that both sides can collect for the claim, the insurer said in a recent article. This doesn't just happen on the technical side – physicians' offices have been known to accidentally submit claims without modifier 26, which causes similar problems. "Without the Modifier 26, the service is denied so the provider then contacts Novitas to request that Modifier 26 be appended to the procedure code in order to receive payment for the professional component of the service," the article said.

Much like the Novitas advice above suggests, a reopening could be requested to fix the issue. But if it keeps happening with the same facility, you should sit down with billing reps from both sides and work through the issue. It's possible that they thought the modifier wasn't necessary or they weren't even aware of its existence, so a quick sit-down session could help fix the problem.