The proper use of coding modifiers can dramatically improve the bottom line for radiology practices. A service or procedure can be further described by using two-digit modifiers when documenting and coding a claim. For radiology practices, there are four commonly used modifiers—26, 59, 76 and 77—that have a significant impact on revenue.
To be clear, there are different categories of modifiers. Pricing modifiers, such as modifier 26, are considered part of the seven-digit procedure code by CMS and are used to determine the reasonable charge for professional fee only service. Statistical/informational modifiers, such as modifiers 59, 76 and 77, are used for documentation purposes and can affect the processing or payment of the code billed.
Modifier 26: Professional Component. Some procedures are a combination of a physician component and a technical (facility or equipment fee) component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. For example, use modifier 26 when a physician interprets but does not perform the test. Most radiology codes, including ultrasounds, x-rays, CT scans, magnetic resonance angiography and MRIs may be billed with modifier 26, or with no modifier at all, indicating that the provider performed both the professional and technical services. This modifier must be reported in the first modifier field.
Modifier 59: Distinct Procedural Service. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-Emergency Medicine services performed on the same day. Documentation must support a different session or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
For example, an inpatient with pneumonia may have multiple chest x-rays on the same day. A single view 71045 would be billed with modifier 59 to separate it from a two-view 71046 done later the same day. Without the 59 modifier, the higher reimbursing procedure (71046) will be paid, and the 71045 CPT code will be denied as global or incidental to the primary procedure.
Modifier 76: Repeat Procedure by Same Physician On the Same Day and Modifier 77: Repeat Procedure by Another Physician On the Same Day. Modifier 76 (same physician) and modifier 77 (another physician) are used to report a repeat procedure or service on the same day and are appended to the procedure to report. The documentation should indicate that a procedure or service was repeated subsequent to the original procedure or service.
For example, when an inpatient requires two chest x-rays on the same day, a claim submitted without modifier 76 or 77 will result in a bundled payment, meaning that the payer will deny the claim for the second test. An inpatient with pneumonia may have multiple chest x-rays with the same number of views in the same day resulting in several 71046 claims. In this case, the first claim would have only the 26 modifier and each additional 71046 claim would have 26 and 76 for the same physician or 26 and 77 for another physician. Without the 76 or 77 modifier, each of the additional procedures would be denied as duplicate to the original.
The compensation radiologists deserve. A true understanding of modifiers, more precise coding and additional documentation training for providers results in improved reimbursement for most medical groups. Applying these practices will help radiologists receive the compensation they deserve both accurately and timely, on the first claim.
Tom Maher is President and CEO of Practicefirst, a privately-owned firm that has provided coding, billing, credentialing and practice management solutions for radiology and other medical specialties for over 50 years. To learn more, call Tom at 866-234-5017.