This review pointed out the lack of understanding of these codes by the payers and physicians. As these codes contain both a professional and a technical component, we look for guidance on documentation from the radiology codes. The primary statement that provides guidance for documentation is a directive that Medicare should pay for a professional component only if there is a written report.
Therefore, we recommend that each service that you bill for includes some separate documentation with the information generated during performance of the test to document the technical component (TC). Use a simple template for the professional component (PC), with at least one statement on test performed, cystometrogram (CMG), bladder pressure, urethral pressure profile (leak point or UPP), abdominal pressure, and electromyogram (EMG). However, as an auditor, we would not down-code the services if there is documentation supporting that the information was reviewed and a diagnosis or opinion on the condition has been formulated.
As far as split billing, it is accurate to report the services provided on the date the service was actually provided. Therefore, your circumstance where the technical component is provided on a different day than the procedural component should be billed as technical component on the day performed (code with modifier –TC) and professional component on the day read (code with modifier –26) on a different day. If the payer requires global billing (billing of the codes with no modifier), we recommend you obtain that directive from the payer in writing.