How to bill Lab, radiology and Venipuncture code with Modifier 26

Jul 30, 2012 | Medical billing basics | 1 comment

Lab and Radiology Billing

When submitting claims for laboratory or radiology services rendered in a hospital setting, inpatient
or outpatient, and you are a professional provider, use modifier 26 to indicate that you are billing
for the professional component only. The hospital will submit claims for the technical component.

When submitting claims for laboratory or radiology services rendered in an office setting and you are a
professional provider, indicate whether or not you are billing for the global fee or only the professional
component. Use modifier 26 to indicate you are billing for the professional component only if
sending the sample to a laboratory. You should also check “yes” in Box 20 of the CMS-1500
or 837 transaction. This allows payment to the laboratory for the technical component. If you
don’t use a modifier and don’t indicate “yes” in Box 20 of the CMS-1500, you will be paid the
global fee. Should the laboratory subsequently bill for the technical component, that claim
will be denied.

Note: Clinical labs billing for services for inpatient hospital patients must bill the facility, not TRICARE, for the lab tests. Repeated failure to follow this rule will cause the clinical lab to have all claims returned to them without processing.
Venipuncture
Venipuncture is denied or paid based on the setting in which it is provided. Denial or payment is also
determined by whether or not the lab results are read by the provider of care. When submitting
venipuncture claims, specify “yes” or “no” in Box 20 of the CMS-1500 or 837 transaction to
indicate if an outside laboratory was utilized. If the labs are drawn in a provider’s office but read
in an outside laboratory, TRICARE pays for the venipuncture.

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1 Comment

  1. Erin Fussinger
    Erin Fussinger on August 16, 2012 at 4:16 pm

    Good information on radiology and modifier 26. Check out our website http://www.medicalreimbursementinc.com for additional information on medical coding and billing topics.