Modifier 26

Many diagnostic codes cover two separate jobs. One is producing the study: the machine, the technologist and the supplies. The other is the physician reading the result and writing it up. Where a code has both parts, Medicare’s physician fee schedule carries relative values for the global service, the professional component and the technical component, and modifier 26 tells the payer the line is for the professional part alone. CMS pays the professional component of radiology services in every setting, whatever the reading physician’s specialty, and treats the written report as part of the interpretation.

Billing the code bare, with no modifier, is global billing, and CMS limits it. It is possible only when the same physician or supplier entity furnishes both components, and the radiology chapter adds that both must be furnished in the same fee schedule payment locality. Putting the same place of service code on both parts does not make a global claim valid. When the physician reads a study someone else performed, or reads it in a different locality, the interpretation is billed on its own with 26, and the claim carries the address and ZIP code of the interpreting physician’s location.

The mistake to watch is a global claim for a study done on a hospital patient. Medicare does not pay a physician or supplier for the technical component of radiology furnished to hospital patients, so the physician’s claim covers the read only and needs 26. Clinical laboratory interpretations that qualify for fee schedule payment follow the same pattern: they are reported on the lab code with modifier 26.