This notice provides guidance on the appropriate use of Modifier 26 (Professional Component) when billing for diagnostic services, consistent with CMS billing principles.
Overview
Some CPT codes represent services that include two distinct parts:
- A professional component, which includes the provider’s work such as supervision, interpretation, and a written report
- A technical component, which includes equipment, supplies, and clinical staff needed to perform the service
Generally, the technical component is reimbursed to the facility or entity that provides the equipment and supports the service.
Billing Guidance
When billing only for the professional component of a service that includes both elements:
- Append Modifier 26 to the appropriate CPT code
- Use Modifier 26 only when the provider performs interpretation and/or supervision of the diagnostic service
Clinical Laboratory Services Limitation
In alignment with CMS guidance:
- Clinical laboratory services generally do not include a separately payable professional component
- Claims submitted with Modifier 26 appended to laboratory CPT/HCPCS codes that do not define a professional component will be denied
Important Considerations
- Do not use Modifier 26 when the CPT code already describes the professional component only
Example: CPT 93010 – Electrocardiogram; interpretation and report only
- Incorrect use of Modifier 26 may result in:
- Claim denials
- Duplicate billing concerns
- Delays in reimbursement
pROVIDER eXPECTATIONS
Providers should review their billing practices to ensure Modifier 26 is applied appropriately. Accurate use supports:
- Proper claim adjudication
- Reduced denials
- Alignment with CMS billing expectations
Action:
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
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