E/M code + procedure code?

“Incident to” billing

Normal newborn care

Lab results review, revisited

In the January 2001 issue [page 23], I noted that modifier −26, “Professional component,” should be added to the appropriate laboratory CPT code to note the interpretation of lab work done outside the office. Since then, several individuals have contacted me to ask whether this means they can code and be reimbursed for the review of results sent to them by the outside laboratory. The answer is no.

The “professional component” refers to the actual interpretation of the laboratory test and preparation of a separate, distinct, identifiable written report. Most outside laboratories do the professional component as part of the test and provide the physician's office with the report of the results. Review of those results provided by the outside lab does not constitute the “professional component” of the test and cannot be coded separately. Only if a physician were to interpret a test done by an outside lab and produce his or her own written report based on that interpretation would it be appropriate to report the lab code with modifier −26.

The rarity of this in family practice is underscored by the fact that two family physician lab experts we contacted couldn't think of an instance in which modifier -26 would be used by family physicians for lab work. One said, if it were used this way, it would probably “raise red flags and require special justification.”

Editor's note:While this department represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will accept the coding and documentation recommended. Because CPT and ICD-9 codes change annually, you should refer to the current CPT and ICD-9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.