Home / Documentation / Billing Modifiers / 26
Documentation

Modifier 26

Definition

Modifier 26 is used to identify the professional component of a service that includes both a professional component (provider interpretation/service) and a technical component (equipment, staff, supplies). The professional component includes the provider's time, skill, and interpretation. Modifier 26 is used by providers who perform only the professional portion, not the technical portion.

When to Use

  1. Radiologist interprets X-ray taken at facility; facility bills technical (70553-TC), radiologist bills interpretation (70553-26)
  2. Cardiologist interprets EKG that was recorded at clinic; cardiologist bills professional only (93000-26)
  3. Ophthalmologist interprets visual field test performed by technician (92081-26 for professional interpretation)
  4. Pathologist reviews biopsy specimen and issues report; surgeon who took specimen does not bill (88304-26)

Documentation Requirements

Document the professional service provided separately from technical. For imaging, note radiologist interpretation time and findings. For lab/pathology, note review of slides/specimens and interpretation. Do not bill both professional (26) and technical (TC) from same provider. Coordinate with facility/lab billing technical component.

Payer-Specific Rules

Payer Acceptance Common Denials Notes
Medicare Accepted; standard split billing CO-20: Charge does not match payer fee schedule Allow 26. Reimburse at RVU percentage for professional. Facility bills TC.
Aetna Accepted; coordinate with facility CO-151: Documentation missing Will pay. Require coordination with facility/lab to avoid duplicate payment.
United Healthcare Accepted; may bundle CO-4: Service bundled Allow 26 in most cases. Some plans bundle professional and technical.
Cigna Accepted with coordination CO-8: Service denied based on plan Pay 26 when properly documented. Deny if facility also bills same code.
Humana Accepted routinely CO-3: Service not covered Standard split billing accepted. Pay based on fee schedule allocation.
  • TC – Technical component. Use when billing equipment/staff/supplies only, not professional service.
  • 80 – Assistant surgeon. Use if assistant surgeon provides professional component of surgical service.
  • 27 – Multiple outpatient hospital evaluation and management visits (older; rarely used).

Common Denials

CARC Code Reason Primary Cause
CO-20 Charge exceeds fee schedule Provider billed full code charge; payer expects reduced charge for 26.
CO-151 Documentation missing No evidence of professional interpretation or service provided.
CO-4 Service bundled in plan Payer contract includes both professional and technical in single reimbursement.

FAQ

Can I bill both 26 and TC from the same facility?

No. One entity bills 26 (professional), another bills TC (technical). Never bill both from same provider.

What percentage of the code's RVU does modifier 26 cover?

Medicare typically reimburses 26 at the RVU percentage designated for professional component. Varies by code (often 40-60% of full RVU).

Do I need modifier 26 on every imaging interpretation?

No. If you own the equipment and staff, bill the full code without 26. Use 26 only when another entity performs the technical component.

Prevent These Denials

Avoid split-billing errors. A co-pilot tracks professional/technical component coordination.

Related Resources

This reference is current as of 2026-03-23. Payer policies change. Always verify against the payer's latest policy documentation.
← Back to Modifier Reference Hub