Modifier Code 26

Certain diagnostic procedures are composed of a technical component and a professional component. Modifier code 26 is added to a procedure code to indicate that the physician has performed the professional component.

Attending physicians should not submit claims for the interpretation of laboratory services or X-ray services.

HMSA does not recognize an additional fee for an interpretation when it is:

• Associated with an evaluation and management (E/M) visit. In such a situation, HMSA considers the diagnostic interpretation of test results a service that is included in the visit.
• Associated with a service for which another provider (e.g., a radiologist) has already performed the professional component (or the total service).

Claims Filing Information

If one of the situations above applies, please do not report the professional component (modifier code 26) separately for laboratory or X-ray services.

Example

Claim contains:

99212
E/M visit for a patient with a severely sprained ankle

73600-26
Radiologic examination, ankle; two views

HMSA will:
Pay for the E/M visit, but not for 73600-26.

Revision History