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Assistance with modifier 26

Leorah Posted Thu 16th of May, 2019 06:48:13 AM
Our doctors are Interventional Neuro Radiologists and Neurologists and they perform many emergency procedures to check for strokes and aneurysms. In doing so, they code catheterization codes 36224 and 36226 many times. For NJ Medicaid the pricing is listed as one line item without any modifier and another line item with a modifier 26. As far as I know, I would only submit codes with a 26 modifier if they are a radiology codes. I am wondering if our doctors need to submit these codes with a 26 modifier or without for NJ Medicaid. Generally, I do not submit these codes to any other insurance company that way, but none of the other insurance companies have that as an option. The AMA guidelines also do not list any requirements of a modifier 26 appended to these codes, and from what I see neither does Supercoder. The price reimbursement rate drops significantly with the appendage of modifier 26 and the rate of reimbursement is significantly lower and more similar to the NYS Medicaid reimbursement rate we receive without the code. We do not want to undercharge and append the modifier if we are allowed to receive the higher rate but also we do not want to later be accused of Medicaid fraud later by not appending modifier 26 and receiving higher payment. When we spoke to Medicaid they told us we should charge the higher fee but they keep saying they are not the coders and do not know how to direct us to discover rules that may only apply to this payer. Please advise thank you Thank you
SuperCoder Answered Fri 17th of May, 2019 07:13:38 AM

In CPT 36224, the provider uses a needle to puncture the site over any peripheral artery, which is most commonly the femoral artery. He places a guidewire through a sheath in the needle and then into the artery. He removes the needle. He then threads the wire into the thoracic aorta and then into the branch of the aortic arch. Then he inserts a catheter into the internal carotid artery. He removes the wire and injects contrast into the artery. He performs the angiography with several X–rays of the same side of the intracranial, carotid, and extracranial arteries and possibly the cervicocerebral arch, as the contrast material flows through these blood vessels. After imaging, he removes the catheter and applies pressure to stop bleeding from the incision site. The provider who performs imaging supervision and interpretation for this procedure reports this code. And almost same procedure performed in the CPT 36226. However, it depends that your doctor performing whole procedure or only radiology services, because there may be rare instances where one provider supervises the radiology service and another provider interprets it. In this case, according to the guidelines, each provider should report the radiology code and append reduced service modifier 52. Each should also append modifier 26 to the code to report only the professional component.

On the other hand, if your doctor performing the complete procedure, then there is no need to append the modifier 26 with the procedure.

For payment of the services, the payer does not pay hospitals separately for supervision and interpretation codes deemed to be ancillary and supportive services to primary diagnostic or therapeutic services. But hospitals should still report the code when performed for statistical purposes.

Hope this helps!

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