I received a response from a representative at Fair Health.
"Data from free standing facilities are included in the Medical module. For many of the services you mention, there is a professional component and a technical component that total the global fee. For cost forecasting, you may just use the global fee (the one displayed with no modifier) for these free-standing facilities. If the service were to be done in an Outpatient facility instead, you'd use the fee from the outpatient product for the technical cost and the -26 modifier data from the Medical for the professional (physician) cost for the total."
From the American Academy of Professional Coders:
What Is Modifier 26?
The professional component is outlined as a physician's service, which may include technician supervision, interpretation of results, and a written report. To claim only the professional portion of a service, CPT® Appendix A (Modifiers) instructs you to append modifier 26 to the appropriate CPT® code.
Appropriate Usage:
- To bill for only the professional component portion of a test when the provider utilizes equipment owned by a hospital/facility
- To report the physician's interpretation of a test, which is separate, distinct, written, and signed
Inappropriate Usage:
- When the same provider performs both the technical and professional components; unless the same provider reports both components and the technical portion is purchased
- Reporting it for re-read results of an interpretation provided by another physician
- Appending it to:
- Global test-only codes
- Professional component-only codes
- Technical component-only codes.
- For example, a facility performs a 12-lead EKG and has an independent physician read the strip: 93005 Tracing only (facility) and 93010 Interpretation and report only (physician).
So for my question above, the free-standing facility has the equipment and employs the technician to do the testing and a radiologist to interpret the test and create a report, would not use the -26 modifier. For a Fair Health cost estimate from this type of facility you would use the medical category without the -26 modifier.
------------------------------
Burt Ashman
Vocational Consultant
burt@outlook.comLafayette, LA United States
------------------------------
Original Message:
Sent: 04-18-2023 10:01
From: Burt Ashman
Subject: Fair Health Question - Medical vs. Outpatient Facility
A surgeon recommends an MRI and x-rays before surgery. The patient will be going to a freestanding imaging center for this testing. Which is correct when using Fair Health?
1. Use the outpatient facility category and include the -26 modifier.
2. Use the medical category and do not include the -26 modifier.
I have been using the medical category with no -26 modifier. The cost in the freestanding imaging center billing I have reviewed falls within the 75th and 80th percentiles of the medical category and I have not seen the -26 used indicating that the provider performed both the professional and technical services.
------------------------------
Burt Ashman
Vocational Consultant
burt@outlook.com
Lafayette, LA United States
------------------------------