Get Pro/Tech Component Refresher From October MPFS Update

Mon, Sep 23, 2019 --

CPT Codes, Medicare

dermatology coding and payment

When you think of professional component and technical component, Medicare’s division of a single code may spring to mind. But the October 2019 update to the Medicare Physician Fee Schedule (MPFS) has a dermatology example that shows there’s more than one way to think about PC/TC. Here are the details.

RVUs for PC + TC = Global

The October MPFS update will change the relative value units (RVUs) for two global dermatology codes, which apply to services used in the detection of skin cancer. The RVUs for the codes, 96931 and 96934, will change so that the global code RVUs equal the values of the professional and technical component codes. The reason is that, just like when a single code is split into professional and technical components, “the global codes (96931/96934) need to sum to the values of the professional and technical component codes (96932 and 96933 for 96931, respectively; and 96935 and 96936 for 96934, respectively),” according to MLN Matters MM11402.

These are the codes involved, their PC/TC indicators on the MPFS, and the RVU changes coming:

  • Global: 96931 (Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion)
    • PC/TC indicator: 4 (Global test only codes)
    • Malpractice RVUs before update: 0.04
    • Malpractice RVUs after update: 0.06 (equals the sum of the malpractice RVUs for the next two codes below)
  • Technical: 96932 (… image acquisition only, first lesion)
    • PC/TC indicator: 3 (Technical component only codes)
    • Malpractice RVUs (no change): 0.02
  • Professional: 96933 (… interpretation and report only, first lesion)
    • PC/TC indicator: 2 (Professional component only codes)
    • Malpractice RVUs (no change): 0.04
  • Global: +96934 (… image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure))
    • PC/TC indicator: 4 (Global test only codes)
    • Practice expense (PE) RVUs before update: 1.94
    • PE RVUs after update: 1.71 (equals the sum of the PE RVUs for the next two codes below)
    • Malpractice RVUs before Oct. 1 update: 0.04
    • Malpractice RVUs after Oct. 1 update: 0.05 (equals the sum of the malpractice RVUs for the next two codes below)
  • Technical: +96935 (… image acquisition only, each additional lesion …)
    • PC/TC indicator: 3 (Technical component only codes)
    • PE RVUs (no change): 1.25
    • Malpractice RVUs (no change): 0.01
  • Professional: +96936 (… interpretation and report only, each additional lesion …)
    • PC/TC indicator: 2 (Professional component only codes)
    • PE RVUs (no change): 0.46
    • Malpractice RVUs (no change): 0.04.

To sum up: The malpractice RVUs for global code 96931 will increase by 0.02. The change for global code +96934 isn’t so positive with malpractice expense RVUs increasing by 0.01 and practice expense RVUs decreasing by 0.23.

Dates to know: The implementation date for these changes is Oct. 7, 2019. That’s when MACs must be ready to process claims using the new information. But the effective date is Jan. 1, 2019. “Medicare contractors shall not search their files to retract payment for claims already paid or to retroactively pay claims. However, contractors shall adjust claims brought to their attention,” according to Medicare Transmittal 4362, CR 11402.

Don’t Assume Modifiers 26 and TC Always Apply

For all of the codes above, which have PC/TC indicators 2, 3, and 4 on the MPFS, you should never append modifier 26 (Professional component) or TC (Technical component). Use the code specific to the component(s) you’re reporting.

According to the MPFS PC/TC indicator definitions, you also should not use modifier 26 or TC when the code has indicator 0 (Physician service codes) or 5 (Incident to codes).

You may use modifier 26 or TC with codes with indicator 1 (Diagnostic tests or radiology services) when you need to indicate you’re reporting a single component.

Pathology and lab coders need to be aware of indicator 6 (Laboratory physician interpretation codes) and 8 (Physician interpretation codes). You should not append TC to these codes.

The remaining PC/TC indicators are 7 (Private practice therapists’ service) and 9 (Concept of professional/technical component does not apply).

What About You?

Do you think it would be simpler for the CPT® code set to provide separate codes for each component so you wouldn’t have to use 26 and TC?

 

 

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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