Medical practices are almost as diverse as people in regards to the arrangements and agreements that exist between physicians and facilities. These varied fiscal arrangements make it necessary for medical entities to have a complete understanding of the nuances of global, professional and technical charges. This allows them to properly bill their charges based on the specific portion of service that the entity is providing to the patient. Understanding the definition of the CPT-4 codes, and modifiers, allows billers to accurately code the appropriate charge codes and payment modifiers.
A challenge that is common in Radiation Oncology coding due to facility based practices, is selecting the correct modifiers that are required to distinguish between the global, professional, and technical components of services. The modifier codes that distinguish these services are ‘26’ for professional components, and ‘TC’ for technical components.
For a facility based provider that is not an employee of the hospital, the professional component of a charge covers the cost of the physician’s professional services only. When billing for the physician’s time and expertise, a 26 modifier is added to global CPT codes. (Professional only codes, like 77427 do not get billed with an appended 26 modifier.)
For example: Typical billing codes used when planning IMRT radiation therapy treatment for a patient are 77301, 77300, 77338. The 26 modifier when added to these codes indicates to the insurance company that the claim is requesting payment for the physician’s services only and not the use of the facility, or other support staff’s services.
In a hospital based radiation therapy center utilizing contract physicians, the technical component of a charge addresses the use of equipment, facilities, non-physician medical staff, supplies, etc. Technical charges do not include the physician's professional fees, but include the use of all other services associated with the visit. (Technical only, like 77418 do not get billed with an appended TC modifier.)
Using the example from above: The treatment planning codes 77301, 77300, and 77338 will have appended to them the TC modifier. This will indicate the charge is for the technical component only. In this case the medical claim is seeking payment for the facility costs and the costs associated with all supplies and staff except for the physician.
When radiation therapy services are performed in a free standing center or a hospital owned facility with employed physicians, all charges will be submitted globally. In other words, a biller will bill global charges when there is no division of the costs associated with a medical service because the service was provided by a single entity. The global charge includes both the professional services as well as all ancillary services (like use of equipment, facilities, non-physician medical staff, supplies, etc.) associated with a patient’s care. (Global charges are never billed with a 26 or TC modifier.)
So far we have discussed two billing scenarios: outpatient hospital based contracted radiation oncologist and a facility employed radiation oncologist. Often a radiation oncologist can provide his or her services in a combination of these two scenarios. They may be part of a free-standing (global) radiation therapy center(s) and also have contracts to provide (professional only) services for hospital based departments.
In this case, it is crucial that office staff pay very close attention when they assign modifiers based on the place of service and the “portion” of the services provided. If a global charge is billed with the ‘26’ modifier, the provider will be reimbursed at a significantly lower rate. (In radiation oncology billing, the technical reimbursement portion always greatly exceeds the professional.) If a professional charge is billed without the ‘26’ modifier, the provider will be overpaid at the global rate and/or could cause great difficulty for the facility when they file for their reimbursement. (Any billing that causes overpayments can be construed by the payer as fraud, so even a simple mistake like this can have significant financial or legal repercussions.)
One way to avoid these types of errors and greatly simply the coding of these complex situations is to utilize advanced medical billing software such as Iridium Suite by Medical Business Systems. Because of programmable “Facility Tracks”, the software is able to recognize when to add a modifier, and which modifier to add based on the facility where the service was rendered.