Forum - Questions & Answers

Oct 8th, 2022 - Aleecorso

Billing using the provider who rendered the service

the proper way to bill for services. I will give you the example of what I need help with. I have two chiropractic doctors one owns the practice and the equipment,  we will call him the "owner" and the other one is someone the owner hired for help we will call him the "helper" both are licensed to do x-rays. The owner will tell the "helper" to go take the x-ray on someone while he (Owner) goes to adjust another patient. When I bill for services such as 72040 and 72100 I understand that both these CPT codes already have both technical and professional components. I do not bill modifiers 26 or TC because it is inappropriate. When I bill I list the Service place which is the "owners tax ID" and group's NPI and the billing place as the "owner" boxes 32 and 33 of the CMS 1500 form but I list the "helper" as the one whom administered the x-ray in 24j which is the rending provider correct. I don't put everything under the "owner" correct?

Oct 13th, 2022 - ChrisW   256  1 

re: Billing using the provider who rendered the service

The way you mentioned billing the claim with the provider (Owner) on the claim, and the Technician (Helper) as the one administering the X-Ray, you are splitting up the code. The claims processor would be looking for the 26/TC modifiers.  If you are intending the reimbursement to go to the Technician, then you would separate the billing and use the appropriate modifiers. If the technician works for the provider, then the provider should receive the payment for the cost of the equipment; in other words, fees for the technical component should be reimbursed to the practice that pays for the cost of the X-Ray machines.

As you can see, it is incorrect to bill the technician as the service provider; in addition, a technician is not considered a provider of service, and, therefore, would not be the rendering provider. Everything should be billed under the rendering provider.

The PC/TC modifiers are intended to split the RVUs for the service, if a CPT code has both PC/TC identified by Medicare Fee Schedule Indicator 1, you can either split them, or the provider will receive reimbursement for both the professional and technical components.  CPT code 72040 does have both components meaning both Professional and Technical can be used with this code; if there is no modifier appended, the provider is paid for both components. It is important to understand how payers use CPT codes. Look at the fee schedule indicators assigned by CMS; most payers follow Medicare Guidelines. However, I suggest consulting with your specific payers.    

Understanding Medicare Physician Fee Schedule (MPFS) Indicators
UHC Reimbursement Policy Number 2022R0012C states the following: “CPT or HCPCS codes assigned a CMS PC/TC Indicator 1 is comprised of a Professional Component and a Technical Component which together constitute the Global Service. The Professional Component (PC), (supervision and interpretation) is reported with modifier 26, and the Technical Component (TC) is reported with modifier TC. The term “professional/technical split” is used to reference a Global Service assigned a PC/TC Indicator 1 that may be “split” into a Professional and Technical Component. CPT or HCPCS codes assigned a PC/TC Indicator 1 are listed in the NPFS. Each Global Service is listed on a separate row, followed immediately by separate rows listing the corresponding Technical Component, and Professional Component.

CPT or HCPCS codes with CMS PC/TC Indicators 0, 2, 3, 4, 5, 7, 8, and 9 are not considered eligible for reimbursement when submitted with modifiers 26 and/or TC. Codes with Indicator 6 are not considered eligible for reimbursement when submitted with modifier TC.”

Verify with your payer if X-Rays are considered medically necessary; under CMS, it is a non-covered service unless it is ordered by an authorized practitioner.  If an authorized ordering practitioner orders the x-ray, then he/she should enter his/her name in Item 17 of the CMS-1500 form and his/her own NPI number in Item 17a of the CMS-1500 form, or the electronic equivalent, as the ordering physician.

If you are a Find-A-Code subscriber, go to the code information page, and look under "Additional Code information" to view the applicable Fee schedule indicators. 

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