TC vs 26

Do you know what the difference is between modifier TC and modifier 26?  If not, you're not alone!  There are many doctors and medical billers who don't know the answer to this question, and they are keeping their practice from collecting money that is rightfully theirs because of it.  Today I will explain the difference to you and tell you how to properly use these modifiers.

TC - This stands for "Technical Component" which is used to indicate the technical part of a diagnostic procedure.

26 - This is the professional component which is the interpretation of the procedure.

To help clarify this I will give two examples.

Example 1:
A patient goes to see his dermatologist to have a few moles removed.  Once removed, as a standard of care, the dermatologist sends these specimens to a laboratory to prepare pathology slides.  When the laboratory sends the slides back to the doctor she reads them and makes a diagnosis.  In this case because the laboratory prepared the slides but did not read them, they would bill this as 88305 - TC whereas the dermatologist who read the slides but did not prepare them would bill 88305 - 26.

Example 2:
A patient goes to her primary care physician because she injured her ankle and thinks it might be sprained. The doctor has her go to a radiology imaging office for x-rays.  When the x-ray images are ready they are sent back to the doctor who reads them and contacts the patient to let her know that her ankle is indeed sprained.  In this case the radiology imaging office would bill 73610 - TC and the doctor who read the x-ray would bill 73610 - 26.

Are you starting to see the trend?  The concept might seem confusing to some, but when you look at these examples it's actually pretty straight forward.  There are of course a few other scenarios I have not yet discussed. 

• What if the dermatologist sends the patient's specimens to a laboratory that both prepares the slides and reads them?  Then the doctor would not bill any pathology and the laboratory would bill 88305 by itself.

• What if the laboratory prepares the slides and reads them, but the dermatologist prefers to read the slides as well, just to make sure the laboratory read them correctly?  Because the laboratory already read the slides and billed them, the doctor cannot bill them again. The patient's insurance company will not pay for the reading twice.

• What if the primary care physician has an in-house x-ray technician that can take the x-ray in the office and give it to him to read within minutes?  Then the doctor would bill a 73610 by itself.

As you can see, when the entire diagnostic procedure is done in one place from start to finish there is no need to use the TC or 26 modifiers.  These modifiers are only used to specify which part of the procedure was done when they are done separately.  Reimbursement from insurance will be higher when neither modifier is used because reimbursement will be for both the technical and professional components. 

NOT USING THESE MODIFIERS PROPERLY COULD LEAD TO INSURANCE FRAUD...
If your office only does one component but not the other and you are billing for both by not using a modifier, this is considered insurance fraud!  By billing the CPT code without the appropriate modifier you are telling the insurance that your office did the diagnostic procedure from start to finish.  If this is consistently done and yet the insurance is getting claims from the laboratory or other provider that has done the other half of the procedure, it will definitely raise a red flag and your office is likely to be audited.

...OR MONEY LEFT ON THE TABLE!
I cannot tell you how many times I have gone to a billing seminar where these modifiers were discussed and heard one of the doctors also attending the seminar say, "I have been doing both the technical and professional components, but someone once told me it had to be billed with a modifier 26, so that's what I've been doing for years!"  Don't blindly trust what someone tells you when it comes to how to bill something.  Don't even blindly trust what I tell you. ALWAYS research and double check on trusted billing websites or if your practice belongs to a medical society you can call them up and ask them your billing questions. It's worth the effort to make sure you are collecting every penny your doctor has worked so hard to earn.