Coding Cues: Modifier-26 indicates "professional component"

June 6, 2008

Our pathology group is a private practice, not part of the hospital where we perform our services. Our new biller maintains that since we're an independent entity, it's not necessary to use any modifiers when billing our services. But we've experienced massive claims rejections recently. Could this be due to the lack of modifier use? If so, should our new biller have anticipated this?

Key Points

Our pathology group is a private practice, not part of the hospital where we perform our services. Our new biller maintains that since we're an independent entity, it's not necessary to use any modifiers when billing our services. But we've experienced massive claims rejections recently. Could this be due to the lack of modifier use? If so, should our new biller have anticipated this?

Yes on both counts. If your billing service is reporting place of service 21 (inpatient hospital) or 22 (outpatient hospital) and you're performing your services in a hospital-owned lab, modifier –26 (professional component) should be used unless the CPT code in question describes the professional component alone. Since the hospital owns the lab, it is billing the technical component of the service, something your billing service should have known.