Community First Health Plans is providing guidance on the appropriate use of Modifier 26 (Professional Component) when billing for diagnostic services. Proper use of Modifier 26 supports accurate claims processing, compliance with CMS billing guidelines, and reduces the likelihood of claim denials.
Overview
Certain CPT® codes represent services that include both a professional component and a technical component.
- The professional component includes the Provider’s work, such as supervision, interpretation of results, and a written report.
- The technical component includes the equipment, supplies, and clinical staff required to perform the service.
Generally, the technical component is reimbursed to the facility or entity that provides the equipment and supports the service.
Billing Guidance
When billing only for the professional component of a service that includes both elements:
- Append Modifier 26 to the appropriate CPT code
- Use Modifier 26 only when the provider performs interpretation and/or supervision of the diagnostic service
Clinical Laboratory Services Limitation
In alignment with CMS guidelines, most clinical laboratory services do not include a separately payable professional component.
Claims submitted with Modifier 26 appended to laboratory CPT or HCPCS codes that do not define a professional component are not reimbursable and will be denied.
Important Considerations
Modifier 26 should not be used when the CPT code already represents the professional component only.
For example: CPT® 93010 – Electrocardiogram; interpretation and report only
Incorrect use of Modifier 26 may result in claim denials, duplicate billing concerns, or delays in reimbursement.
pROVIDER eXPECTATIONS
Providers are encouraged to review billing practices to ensure Modifier 26 is used appropriately when reporting professional services. Proper use supports accurate claim adjudication, reduced denials, and alignment with CMS billing standards.
KEY TAKEAWAY
Modifier 26 should be used only when billing the professional component of a diagnostic service that includes both professional and technical elements. Use must be supported by appropriate documentation and aligned with CMS coding guidelines.
Action:
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
To access all Provider alerts:
- Log into the Community First Provider Portal
- Go to CommunityFirstHealthPlans.com/Provider-News
- Sign up for the Community First Provider eNewsletter