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May 22nd, 2014 - Elleon 1 

Modifiers TC and 26

I work for a small police department. When an inmate has to go to the ER, by state law we are only required to pay the Medicaid rate. We do not have any kind of insurance that covers this, so it comes directly out of our budget.

A person was sent to the ER after fleeing the police and crashing his vehicle. He had a CT scan of his head w/o contrast (70450) and an x-ray of his spine (72100). We received a bill from the hospital as well as the physician's office billing these two CPT® codes with no modifiers.

Forgive my ignorance, but I've done a little research and it would seem to me that the hospital should have used the TC modifier and the physician's office should have used the 26 modifier. By not using the modifiers, isn't this considered "global" billing and essentially the hospital and physician's office are billing for the same service?

Because we are such a small agency, every little bit we can save helps, so any guidance you can give me is greatly appreciated.

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May 23rd, 2014 - blm321 27 

re: Modifiers TC and 26

hmmm, the physician that interpreted the images is not employed by the hospital if you are receiving a separate bill. You are correct in the TC (technical component) and 26 (interpretation) modifiers.

Now, there is a difference in price for coding. If the hospital uses TC, they get a PORTION, and the physician uses 26, they get the other PORTION. If no modifier is used, the full allowable is paid.

Example: (not real prices)
72100 Allow $36.00

72100 TC Allow $24.43
72100 26 Allow $12.09

You shouldn't pay full allow to BOTH. It should be priced out accordingly. I am in Arizona, and I have access to Medicare Fee Schedule. Not sure if you can find your state on the CMS website. But it is a good negotiating tool if you can. Good luck!

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May 23rd, 2014 - Elleon 1 

re: Modifiers TC and 26

Thank you for taking the time to answer my question. It wasn't easy, but I did manage to find the Medicaid fee schedules in my state (Georgia) through the Department of Community Health on line.

Your answer has given me the assurance that I'll know what I'm talking about when dealing with these two bills. I appreciate your help!

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May 23rd, 2014 - Codapedia Editor 1,399 

re: Modifiers TC and 26

The hospital and physician may have submitted them with the correct modifiers, but they won't necessarily show on the bill to you.

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May 24th, 2014 - LBAROGIANIS 250 

re: Modifiers TC and 26

Unfortunately, there will always be 2-3 bills in an emergency visit. One for the hospital, which is a facility bill (usage of equipment, supllies, etc.), then the physician bill (who is treating the patient), then possible xrays (interpretation) or what not, they also bill seperately. Physicians mostly do not work for hospitals. They are like subcontractors. They work for themselves.

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