Modifier TC
Definition:
• Technical Component refers to certain procedures that are a combination of a physician component and a technical component. Using modifier TC identifies the technical component.
Appropriate Usage:
• To bill for only the technical component portion of a test
• Procedures that have a “1” in the PC/TC field on the MPFSDB
• Procedures falling into the following types of service; 1-Medical care/Injections 2-Surgery, 4-Radiology, 5-Lab, 6-Radiation Therapy and 8-Assistant Surgeon
Inappropriate Usage:
• When the same provider performs both the technical and professional, unless the same provider reports both components and the technical portion is purchased
• Appending it to:
• Professional component only procedure codes identified on the
MPFSDB by a “2” in the PC/TC column
• Global test only procedure codes identified on the MPFSDB by a “4” in the PC/TC Column
• Technical component only procedure codes identified on the MPFSDB by a “3” in the PC/TC column
Additional Information:
• Modifier 26 and TC are considered payment modifiers and must be reported in the first modifier field
• When a global service is performed, it should be coded without modifiers. Do not report a procedure code with both modifiers 26 and TC
• The payment for the technical component portion of a test includes the practice expense and the malpractice expense
• Technical component procedures are institutional and should not be billed separately by the physician in an outpatient or inpatient location.
Example:
The provider is appropriately billing for just the technical portion of a screening mammogram performed on the left side.
The provider is incorrectly billing for both the professional and technical services of a screening mammogram, on the left side on the same line.
Modifier TC Technical Component.
Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.
Reimbursement Guidelines usage of Modifier 26 and TC
It is never appropriate for the technical and professional components to be unbundled and reported separately under the same TIN number (whether on separate line items of a single claim or on separate claims).
When determining if the technical and professional components were performed by the “same provider” or by different providers, if both components will be billed under the same tax ID number (TIN) then both components were performed by the same provider and are not eligible to be reported as separate components. Instead the global service should be billed without modifier TC or 26.
Example of Payment Rates for the TC, 26, Global Rates:
Procedure Code Modifier Component Price
76705 26 Professional $28.24
76705 TC Technical $82.00
76705 Global Professional + Technical $110.23
Example:
If the x-ray equipment is jointly owned by the physicians in a clinic, then the clinic must obtain a separate TIN number in order to separately submit the technical component (TC) of the service.
If the clinic has not obtained a separate TIN (and a separate contract with Moda Health to be participating), then the global service must be billed by the interpreting clinic physician. The clinic must manage the equitable distribution of reimbursement for the technical component of the service internally through accounting and the joint ownership agreement for the shared equipment.
When the technical and professional components of a procedure are unbundled and billed to Moda Health under the same TIN, the Moda Health claims processing system will process the component procedures in a variety of ways (due to system constraints).
• Often the system will deny one component as a subset to the other component, resulting in an underpayment. In these situations, no override or bypass will be given for the edit. Moda Health requires a corrected claim with the procedure billed as a global service (without -TC or -26 modifier) for any adjustment or additional reimbursement to be considered.
• The system may rebundle the component services into the global service. If this occurs, the claim will not be adjusted to process the components on separate lines. If the components were provided by separate entities, each component must be billed under a separate TIN on separate claims, and a corrected claim set will be required.
• In some cases both components may be separately allowed, but the total allowed fee will not be any higher than if the service had been correctly billed as the global service
Only the components that have been actually performed by the billing provider may be billed to Moda Health.
Submitting Only the Professional Component
• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1, 6, or 8 (see field 20 on the MPFSDB) will be allowed with modifier 26 appended.
• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 7, or 9 will be denied when submitted with modifier 26 appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.
Submitting Only the Technical Component
• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1 (see field 20 on the MPFSDB) will be allowed when modifier TC is appended.
• Procedure code with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 6, 7, 8, or 9 will be denied when submitted with modifier TC appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.
Definitions of Professional and Technical Components and Billing Codes
• The PC of a service is for physician work interpreting a diagnostic test or performing a procedure, and includes indirect practice and malpractice expenses related to that work. Modifier 26 is used with the billing code to indicate that the PC is being billed.
• The TC is for all non-physician work, and includes administrative, personnel and capital (equipment and facility) costs, and related malpractice expenses. Modifier TC is used with the billing code to indicate that the TC is being billed.
PC and TC do not apply to physician services that cannot be distinctly split into professional and technical components. Modifiers PC and TC may not be used with these billing codes. For example: A diagnostic service or test that cannot be distinctly split between TC and PC is considered to be a global test or service. Examples of global tests/services are radiation treatment delivery (CPT codes 77401-77416).
Review of Global procedure
A global procedure contains both professional and technical components:
* The professional component (PC) represents the supervision and interpretation of a procedure provided by the physician or other healthcare professional. It is identified by appending modifier 26 to the procedure code.
* The technical component (TC) represents the cost of the equipment,supplies and personnel to perform the procedure. It is identified by appending modifier TC to the procedure code.
* A global service includes both professional and technical components.
The global service is identified by reporting the eligible code without modifier 26 or TC.
* A standalone procedure code describes selected diagnostic tests for which there are associated codes that describe (a) the professional component of the test only, (b) the technical component of the test only and (c) the global test only. Modifiers 26 and TC cannot be used with these codes.
Medica uses the Center for Medicare and Medicaid Services (CMS) Professional Component/Technical Component (PC/TC) indicators in the National Physician Fee Schedule (NPFS) Relative Value File to determine whether a Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code is eligible for separate reimbursement for professional and technical services.
The NPFS Relative Value File containing the status indicator assignments is updated quarterly and can be located on the following CMS website:
CMS NPFS PC/TC Status Indicators
Reimbursement will be allowed for the professional and technical components or for the global procedure but not for both with the exception of certain laboratory services codes with a status indicator of 6. Medica will reimburse the professional component and the global code by the same or different physician or healthcare professional for status indicator 6 codes only. Modifier TC cannot be used with these codes.
Reimbursement of the professional component, technical component and the global code will also be based on the physician specialty and the CMS place of service (POS) code submitted on the claim form. The place of service definitions
Professional and Technical Components Policy Page 2 of 4 are described in the CMS Place of Service Codes for Professional Claims database as described below:
CMS POS
Definitions Modifier 26 – Professional Component. Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
Modifier TC – Technical Component. Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier ‘TC’ to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.
Reimbursement Guidelines
Procedures that are comprised of both a technical and professional component are identified on the National Medicare Physician Fee Schedule Database (MPFSDB) in Field 20 with a Professional Component (PC)/Technical Component (TC) Indicator of “1”. It is never appropriate for the technical and professional components to be unbundled and reported separately under the same TIN number (whether on separate line items of a single claim or on separate claims). (CPT Assistant3) When determining if the technical and professional components were performed by the “same provider” or by different providers, if both components will be billed under the same tax ID number (TIN) then both components were performed by the same provider and are not eligible to be reported as separate components. Instead the global service should be billed without modifier TC r 26.
Example:
If the x-ray equipment is jointly owned by the physicians in a clinic, then the clinic must obtain a separate TIN number in order to separately submit the technical component (TC) of the service.
If the clinic has not obtained a separate TIN (and a separate contract with Moda Health tobe participating), then the global service must be billed by the interpreting clinic physician.
The clinic must manage the equitable distribution of reimbursement for the technical component of the service internally through accounting and the joint ownership agreement for the shared equipment.
When the technical and professional components of a procedure are unbundled and billed to Moda Health under the same TIN, the Moda Health claims processing system will process the component procedures in a variety of ways (due to system constraints).
• Often the system will deny one component as a subset to the other component, resulting in an underpayment. In these situations, no override or bypass will be given for the edit.
Moda Health requires a corrected claim with the procedure billed as a global service (without -TC or -26 modifier) for any adjustment or additional reimbursement to be considered.
• The system may rebundle the component services into the global service. If this occurs, the claim will not be adjusted to process the components on separate lines.
If the components were provided by separate entities, each component must be billed under a separate TIN on separate claims, and a corrected claim set will be required.
• In some cases both components may be separately allowed, but the total allowed fee will not be any higher than if the service had been correctly billed as the global service.
Only the components that have been actually performed by the billing provider may be billed to Moda Health. If only one of the components has been performed, charges may not be submitted to Moda Health for the component that has not been performed.
Submitting Only the Technical Component
• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1 (see field 20 on the MPFSDB) will be allowed when modifier TC is appended.
• Procedure code with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 6, 7, 8, or 9 will be denied when submitted with modifier TC appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.
UnitedHealthcare Community Plan Professional/Technical Splits
UnitedHealthcare Community Plan uses the Center for Medicare and Medicaid Services’ (CMS) PC/TC indicators as set forth in the “CMS Payment Policies” under the National Physician Fee Schedule Relative Value File to determine whether a CPT or HCPCS procedure code is eligible for separate professional and technical services reimbursement. CPT or HCPCS codes assigned a CMS PC/TC Indicator 1 are comprised of a Professional Component and a Technical Component which together constitute the Global Service. The Professional Component (PC), (supervision and interpretation) is reported with modifier 26, and the Technical Component (TC) is reported with modifier TC.
The term “professional/technical split” is used to reference a Global Service assigned a PC/TC Indicator 1 that ay be “split” into a Professional and Technical Component. CPT or HCPCS codes assigned a PC/TC Indicator 1 are listed in the National Physician Fee Schedule Relative Value File. Each Global Service is listed on a separate row followed immediately by separate rows listing the corresponding Technical Component, and Professional Component.
CPT or HCPCS codes with CMS PC/TC indicators 0, 2, 3, 4, 5, 7, 8, and 9 are not considered eligible for reimbursement when submitted with modifiers 26 and/or TC.
CPT or HCPCS codes with CMS PC/TC indicator 6 are not considered eligible for reimbursement when submitted with modifier TC.
CMS publishes this information in the “Physician Fee Schedule, PFS Relative Value Files” page, accessible through the following website:
Physician Fee Schedule Relative Value Files UnitedHealthcare Community Plan’s percentage splits are developed on a national level from the CMS NonFacility Total Resource Based Relative Value Scale (RBRVS) based percentage splits. UnitedHealthcare Community Plan’s splits are updated quarterly and differ no more than 2.5% (for each CPT and HCPCS code) rom the CMS Non-Facility Total RBRVS based percentage splits. The current splits are attached to this policy in the next section. services assigned a PC/TC Indicator 1 that CMS indicates may be carrier-priced, or those for which CMS does not develop RVUs are considered Gap Codes.
Gap Fill Codes: When data is available for Gap Codes, UnitedHealthcare Community Plan uses the relative values published in the first quarter update of the Optum The Essential RBRVS publication for the current calendar year.
2016A UnitedHealthcare Community Plan Professional Technical Component Policy Gap Fill Codes Gap Codes that are eligible for PC/TC per CMS but do not have RVUs established, or data available for gap fill, are included in the “Codes Subject to the CMS PC/TC Concept Without RVU Splits” list below and are allowed at 100% of the Allowable Amount for both the Professional Component and Technical Component. 2016A UnitedHealthcare Community Plan Codes Subject to the Professional Technical Concept without RVU Splits
When a physician or other health care professional provides the equipment to perform the service or procedure in a facility POS only the facility may be reimbursed for the Technical Component of the service or procedure. Based on the CMS PC/TC indicators, UnitedHealthcare Community Plan considers the Technical Component to be a service or procedure that has a:
* CMS PC/TC Indicator 1 (Diagnosic Test), and is reported with modifier TC; or
* CMS PC/TC Indicator 3 (Technical Component Only Codes), and is reported without modifier TC.
Services Reported in a CMS POS 24 (Ambulatory Surgical Center)
Consistent with CMS guidelines, UnitedHealthcare Community Plan will not reimburse physicians or other health care professionals for the Technical Component of services included in the Ambulatory Surgery Center Fee Schedule (ASCFS) Addendum BB and reported with a CMS POS 24 as the ambulatory surgical center (ASC) is reimbursed for the Technical Component.
The Technical Component of services reported on a CM-1500 claim form with an SG modifier (Ambulatory surgical center [ASC] facility service) is not reimbursed as a professional claim. Claim lines reported with modifier SG indicate a facility charge and are reimbursed as a facility claim.
PC/TC Indicator 1 Codes
For codes included in the ASCFS Addendum BB PC/TC Indicator 1 Codes list, only the Professional Component (PC, modifier 26) will be reimbursed.
* When reported globally (no modifier), the Technical Component of the code will not be reimbursed.
* When reported with modifier TC, the code will not be reimbursed.
Payment Conditions for Imaging Services
Generally, imaging services are split into technical and professional components (the TC and PC), each separately billable to the local Medicare contractor. Medicare pays under the MPFS for the TC of imaging services furnished to Medicare beneficiaries who are not patients of any hospital, and who receive services in a physician’s office, a freestanding imaging or radiation oncology center, ambulatory surgical center (ASC), or other setting that is not part of a hospital.
When imaging services are furnished in a leased hospital radiology department to a beneficiary who is neither an inpatient nor an outpatient of any hospital, both the PC and the TC of the services are payable under the MPFS by the carrier or A/B MAC.
If image guidance is used 75989 with modifier 26 should be use Modifiers
Modifiers explain that a procedure or service was changed without changing the definition of the CPT code set. Here are some common modifiers related to the use of ultrasound procedures.
26-Professional Component A physician who performs the interpretation of an ultrasound exam in the hospital outpatient setting may submit a charge for the professional component of the ultrasound service using a modifier (-26) appended to the ultrasound code.
Definitions of Professional and Technical Components and Billing Codes
• The PC of a service is for physician work interpreting a diagnostic test or performing a procedure, and includes indirect practice and malpractice expenses related to that work. Modifier 26 is used with the billing code to indicate that the PC is being billed.
• The TC is for all non-physician work, and includes administrative, personnel and capital (equipment and facility) costs, and related malpractice expenses. Modifier TC is used with the billing code to indicate that the TC is being billed. PC and TC do not apply to physician services that cannot be distinctly split into professional and technical components.
Modifiers PC and TC may not be used with these billing codes. For example: A diagnostic service or test that cannot be distinctly split between TC and PC is considered to be a global test or service. Examples of global tests/services are radiation treatment delivery (Procedure codes 77401-77416).
Reading CMS PC/TC indicator – policy statement
A global procedure contains both professional and technical components:
Definition:
• Technical Component refers to certain procedures that are a combination of a physician component and a technical component. Using modifier TC identifies the technical component.
Appropriate Usage:
• To bill for only the technical component portion of a test
• Procedures that have a “1” in the PC/TC field on the MPFSDB
• Procedures falling into the following types of service; 1-Medical care/Injections 2-Surgery, 4-Radiology, 5-Lab, 6-Radiation Therapy and 8-Assistant Surgeon
Inappropriate Usage:
• When the same provider performs both the technical and professional, unless the same provider reports both components and the technical portion is purchased
• Appending it to:
• Professional component only procedure codes identified on the
MPFSDB by a “2” in the PC/TC column
• Global test only procedure codes identified on the MPFSDB by a “4” in the PC/TC Column
• Technical component only procedure codes identified on the MPFSDB by a “3” in the PC/TC column
Additional Information:
• Modifier 26 and TC are considered payment modifiers and must be reported in the first modifier field
• When a global service is performed, it should be coded without modifiers. Do not report a procedure code with both modifiers 26 and TC
• The payment for the technical component portion of a test includes the practice expense and the malpractice expense
• Technical component procedures are institutional and should not be billed separately by the physician in an outpatient or inpatient location.
Example:
The provider is appropriately billing for just the technical portion of a screening mammogram performed on the left side.
The provider is incorrectly billing for both the professional and technical services of a screening mammogram, on the left side on the same line.
Modifier TC Technical Component.
Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.
Reimbursement Guidelines usage of Modifier 26 and TC
It is never appropriate for the technical and professional components to be unbundled and reported separately under the same TIN number (whether on separate line items of a single claim or on separate claims).
When determining if the technical and professional components were performed by the “same provider” or by different providers, if both components will be billed under the same tax ID number (TIN) then both components were performed by the same provider and are not eligible to be reported as separate components. Instead the global service should be billed without modifier TC or 26.
Example of Payment Rates for the TC, 26, Global Rates:
Procedure Code Modifier Component Price
76705 26 Professional $28.24
76705 TC Technical $82.00
76705 Global Professional + Technical $110.23
Example:
If the x-ray equipment is jointly owned by the physicians in a clinic, then the clinic must obtain a separate TIN number in order to separately submit the technical component (TC) of the service.
If the clinic has not obtained a separate TIN (and a separate contract with Moda Health to be participating), then the global service must be billed by the interpreting clinic physician. The clinic must manage the equitable distribution of reimbursement for the technical component of the service internally through accounting and the joint ownership agreement for the shared equipment.
When the technical and professional components of a procedure are unbundled and billed to Moda Health under the same TIN, the Moda Health claims processing system will process the component procedures in a variety of ways (due to system constraints).
• Often the system will deny one component as a subset to the other component, resulting in an underpayment. In these situations, no override or bypass will be given for the edit. Moda Health requires a corrected claim with the procedure billed as a global service (without -TC or -26 modifier) for any adjustment or additional reimbursement to be considered.
• The system may rebundle the component services into the global service. If this occurs, the claim will not be adjusted to process the components on separate lines. If the components were provided by separate entities, each component must be billed under a separate TIN on separate claims, and a corrected claim set will be required.
• In some cases both components may be separately allowed, but the total allowed fee will not be any higher than if the service had been correctly billed as the global service
Only the components that have been actually performed by the billing provider may be billed to Moda Health.
Submitting Only the Professional Component
• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1, 6, or 8 (see field 20 on the MPFSDB) will be allowed with modifier 26 appended.
• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 7, or 9 will be denied when submitted with modifier 26 appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.
Submitting Only the Technical Component
• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1 (see field 20 on the MPFSDB) will be allowed when modifier TC is appended.
• Procedure code with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 6, 7, 8, or 9 will be denied when submitted with modifier TC appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.
Definitions of Professional and Technical Components and Billing Codes
• The PC of a service is for physician work interpreting a diagnostic test or performing a procedure, and includes indirect practice and malpractice expenses related to that work. Modifier 26 is used with the billing code to indicate that the PC is being billed.
• The TC is for all non-physician work, and includes administrative, personnel and capital (equipment and facility) costs, and related malpractice expenses. Modifier TC is used with the billing code to indicate that the TC is being billed.
PC and TC do not apply to physician services that cannot be distinctly split into professional and technical components. Modifiers PC and TC may not be used with these billing codes. For example: A diagnostic service or test that cannot be distinctly split between TC and PC is considered to be a global test or service. Examples of global tests/services are radiation treatment delivery (CPT codes 77401-77416).
Review of Global procedure
A global procedure contains both professional and technical components:
* The professional component (PC) represents the supervision and interpretation of a procedure provided by the physician or other healthcare professional. It is identified by appending modifier 26 to the procedure code.
* The technical component (TC) represents the cost of the equipment,supplies and personnel to perform the procedure. It is identified by appending modifier TC to the procedure code.
* A global service includes both professional and technical components.
The global service is identified by reporting the eligible code without modifier 26 or TC.
* A standalone procedure code describes selected diagnostic tests for which there are associated codes that describe (a) the professional component of the test only, (b) the technical component of the test only and (c) the global test only. Modifiers 26 and TC cannot be used with these codes.
Medica uses the Center for Medicare and Medicaid Services (CMS) Professional Component/Technical Component (PC/TC) indicators in the National Physician Fee Schedule (NPFS) Relative Value File to determine whether a Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code is eligible for separate reimbursement for professional and technical services.
The NPFS Relative Value File containing the status indicator assignments is updated quarterly and can be located on the following CMS website:
CMS NPFS PC/TC Status Indicators
Reimbursement will be allowed for the professional and technical components or for the global procedure but not for both with the exception of certain laboratory services codes with a status indicator of 6. Medica will reimburse the professional component and the global code by the same or different physician or healthcare professional for status indicator 6 codes only. Modifier TC cannot be used with these codes.
Reimbursement of the professional component, technical component and the global code will also be based on the physician specialty and the CMS place of service (POS) code submitted on the claim form. The place of service definitions
Professional and Technical Components Policy Page 2 of 4 are described in the CMS Place of Service Codes for Professional Claims database as described below:
CMS POS
Definitions Modifier 26 – Professional Component. Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
Modifier TC – Technical Component. Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier ‘TC’ to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.
Reimbursement Guidelines
Procedures that are comprised of both a technical and professional component are identified on the National Medicare Physician Fee Schedule Database (MPFSDB) in Field 20 with a Professional Component (PC)/Technical Component (TC) Indicator of “1”. It is never appropriate for the technical and professional components to be unbundled and reported separately under the same TIN number (whether on separate line items of a single claim or on separate claims). (CPT Assistant3) When determining if the technical and professional components were performed by the “same provider” or by different providers, if both components will be billed under the same tax ID number (TIN) then both components were performed by the same provider and are not eligible to be reported as separate components. Instead the global service should be billed without modifier TC r 26.
Example:
If the x-ray equipment is jointly owned by the physicians in a clinic, then the clinic must obtain a separate TIN number in order to separately submit the technical component (TC) of the service.
If the clinic has not obtained a separate TIN (and a separate contract with Moda Health tobe participating), then the global service must be billed by the interpreting clinic physician.
The clinic must manage the equitable distribution of reimbursement for the technical component of the service internally through accounting and the joint ownership agreement for the shared equipment.
When the technical and professional components of a procedure are unbundled and billed to Moda Health under the same TIN, the Moda Health claims processing system will process the component procedures in a variety of ways (due to system constraints).
• Often the system will deny one component as a subset to the other component, resulting in an underpayment. In these situations, no override or bypass will be given for the edit.
Moda Health requires a corrected claim with the procedure billed as a global service (without -TC or -26 modifier) for any adjustment or additional reimbursement to be considered.
• The system may rebundle the component services into the global service. If this occurs, the claim will not be adjusted to process the components on separate lines.
If the components were provided by separate entities, each component must be billed under a separate TIN on separate claims, and a corrected claim set will be required.
• In some cases both components may be separately allowed, but the total allowed fee will not be any higher than if the service had been correctly billed as the global service.
Only the components that have been actually performed by the billing provider may be billed to Moda Health. If only one of the components has been performed, charges may not be submitted to Moda Health for the component that has not been performed.
Submitting Only the Technical Component
• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1 (see field 20 on the MPFSDB) will be allowed when modifier TC is appended.
• Procedure code with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 6, 7, 8, or 9 will be denied when submitted with modifier TC appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.
UnitedHealthcare Community Plan Professional/Technical Splits
UnitedHealthcare Community Plan uses the Center for Medicare and Medicaid Services’ (CMS) PC/TC indicators as set forth in the “CMS Payment Policies” under the National Physician Fee Schedule Relative Value File to determine whether a CPT or HCPCS procedure code is eligible for separate professional and technical services reimbursement. CPT or HCPCS codes assigned a CMS PC/TC Indicator 1 are comprised of a Professional Component and a Technical Component which together constitute the Global Service. The Professional Component (PC), (supervision and interpretation) is reported with modifier 26, and the Technical Component (TC) is reported with modifier TC.
The term “professional/technical split” is used to reference a Global Service assigned a PC/TC Indicator 1 that ay be “split” into a Professional and Technical Component. CPT or HCPCS codes assigned a PC/TC Indicator 1 are listed in the National Physician Fee Schedule Relative Value File. Each Global Service is listed on a separate row followed immediately by separate rows listing the corresponding Technical Component, and Professional Component.
CPT or HCPCS codes with CMS PC/TC indicators 0, 2, 3, 4, 5, 7, 8, and 9 are not considered eligible for reimbursement when submitted with modifiers 26 and/or TC.
CPT or HCPCS codes with CMS PC/TC indicator 6 are not considered eligible for reimbursement when submitted with modifier TC.
CMS publishes this information in the “Physician Fee Schedule, PFS Relative Value Files” page, accessible through the following website:
Physician Fee Schedule Relative Value Files UnitedHealthcare Community Plan’s percentage splits are developed on a national level from the CMS NonFacility Total Resource Based Relative Value Scale (RBRVS) based percentage splits. UnitedHealthcare Community Plan’s splits are updated quarterly and differ no more than 2.5% (for each CPT and HCPCS code) rom the CMS Non-Facility Total RBRVS based percentage splits. The current splits are attached to this policy in the next section. services assigned a PC/TC Indicator 1 that CMS indicates may be carrier-priced, or those for which CMS does not develop RVUs are considered Gap Codes.
Gap Fill Codes: When data is available for Gap Codes, UnitedHealthcare Community Plan uses the relative values published in the first quarter update of the Optum The Essential RBRVS publication for the current calendar year.
2016A UnitedHealthcare Community Plan Professional Technical Component Policy Gap Fill Codes Gap Codes that are eligible for PC/TC per CMS but do not have RVUs established, or data available for gap fill, are included in the “Codes Subject to the CMS PC/TC Concept Without RVU Splits” list below and are allowed at 100% of the Allowable Amount for both the Professional Component and Technical Component. 2016A UnitedHealthcare Community Plan Codes Subject to the Professional Technical Concept without RVU Splits
When a physician or other health care professional provides the equipment to perform the service or procedure in a facility POS only the facility may be reimbursed for the Technical Component of the service or procedure. Based on the CMS PC/TC indicators, UnitedHealthcare Community Plan considers the Technical Component to be a service or procedure that has a:
* CMS PC/TC Indicator 1 (Diagnosic Test), and is reported with modifier TC; or
* CMS PC/TC Indicator 3 (Technical Component Only Codes), and is reported without modifier TC.
Services Reported in a CMS POS 24 (Ambulatory Surgical Center)
Consistent with CMS guidelines, UnitedHealthcare Community Plan will not reimburse physicians or other health care professionals for the Technical Component of services included in the Ambulatory Surgery Center Fee Schedule (ASCFS) Addendum BB and reported with a CMS POS 24 as the ambulatory surgical center (ASC) is reimbursed for the Technical Component.
The Technical Component of services reported on a CM-1500 claim form with an SG modifier (Ambulatory surgical center [ASC] facility service) is not reimbursed as a professional claim. Claim lines reported with modifier SG indicate a facility charge and are reimbursed as a facility claim.
PC/TC Indicator 1 Codes
For codes included in the ASCFS Addendum BB PC/TC Indicator 1 Codes list, only the Professional Component (PC, modifier 26) will be reimbursed.
* When reported globally (no modifier), the Technical Component of the code will not be reimbursed.
* When reported with modifier TC, the code will not be reimbursed.
Payment Conditions for Imaging Services
Generally, imaging services are split into technical and professional components (the TC and PC), each separately billable to the local Medicare contractor. Medicare pays under the MPFS for the TC of imaging services furnished to Medicare beneficiaries who are not patients of any hospital, and who receive services in a physician’s office, a freestanding imaging or radiation oncology center, ambulatory surgical center (ASC), or other setting that is not part of a hospital.
When imaging services are furnished in a leased hospital radiology department to a beneficiary who is neither an inpatient nor an outpatient of any hospital, both the PC and the TC of the services are payable under the MPFS by the carrier or A/B MAC.
If image guidance is used 75989 with modifier 26 should be use Modifiers
Modifiers explain that a procedure or service was changed without changing the definition of the CPT code set. Here are some common modifiers related to the use of ultrasound procedures.
26-Professional Component A physician who performs the interpretation of an ultrasound exam in the hospital outpatient setting may submit a charge for the professional component of the ultrasound service using a modifier (-26) appended to the ultrasound code.
Definitions of Professional and Technical Components and Billing Codes
• The PC of a service is for physician work interpreting a diagnostic test or performing a procedure, and includes indirect practice and malpractice expenses related to that work. Modifier 26 is used with the billing code to indicate that the PC is being billed.
• The TC is for all non-physician work, and includes administrative, personnel and capital (equipment and facility) costs, and related malpractice expenses. Modifier TC is used with the billing code to indicate that the TC is being billed. PC and TC do not apply to physician services that cannot be distinctly split into professional and technical components.
Modifiers PC and TC may not be used with these billing codes. For example: A diagnostic service or test that cannot be distinctly split between TC and PC is considered to be a global test or service. Examples of global tests/services are radiation treatment delivery (Procedure codes 77401-77416).
Reading CMS PC/TC indicator – policy statement
A global procedure contains both professional and technical components:
** The professional component (PC) represents the supervision and interpretation of a procedure provided by the physician or other healthcare professional. It is identified by appending modifier 26 to the procedure code.
** The technical component (TC) represents the cost of the equipment, supplies and personnel to perform the procedure. It is identified by appending modifier TC to the procedure code.
** A global service includes both professional and technical components.
The global service is identified by reporting the eligible code without modifier 26 or TC.
** A standalone procedure code describes selected diagnostic tests for which there are associated codes that describe (a) the professional component of the test only, (b) the technical component of the test only and (c) the global test only. Modifiers 26 and TC cannot be used with these codes.
Medica uses the Center for Medicare and Medicaid Services (CMS) Professional Component/Technical Component (PC/TC) indicators in the National Physician Fee Schedule (NPFS) Relative Value File to determine whether a Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code is eligible for separate reimbursement for
professional and technical services.
The NPFS Relative Value File containing the status indicator assignments is updated quarterly and can be located on the following CMS website:
CMS NPFS
CMS NPFS PC/TC Status Indicators
Reimbursement will be allowed for the professional and technical components or for the global procedure but not for both with the exception of certain laboratory services codes with a status indicator of 6. Medica will reimburse the professional component and the global code by the same or different physician or healthcare professional for status indicator 6 codes only. Modifier TC cannot be used with these codes.
For services that are provided in a facility POS 19, 21, 22, 23, 26, 34, 51, 52, 56, or 61, and that are subject to the professional/technical concept or that have both professional and technical components according to the CMS PC/TC indicators list, Medica will reimburse the interpreting physician or other health care professional only the professional component as the facility is reimbursed for the technical component of the service. To be considered for professional component
reimbursement, a service or procedure must have a:
** CMS PC/TC Indicator 1, and must be reported with modifier 26;
** CMS PC/TC Indicator 2 (professional component only codes), and must be reported without modifier 26 or TC; or
** CMS PC/TC Indicator 6 (laboratory physician interpretation codes) and must be reported with modifier 26.
Consistent with CMS, Medica will not allow reimbursement to physicians and other healthcare professionals for “Incident To” codes identified with a CMS PC/TC indicator 5 when reported in a facility place of service (POS 19, 21, 22, 23, 24, 26, 34, 51, 52, 56, or 61) regardless of whether a modifier is reported with the code. CPT coding guidelines specify that these codes are not intended to be reported by a physician in a facility setting. In addition, CPT code 96110 is not eligible for reimbursement when reported in a facility place of service.
For Clinical Laboratory Interpretation Services provided in a facility setting, Medica will reimburse the pathologist or independent laboratory for clinical laboratory codes billed with modifier 26, as these services result in a written narrative report of results and analysis by the physician. Medica follows CMS PC/TC policy indicators in determining which services qualify for reimbursement of modifier 26:
** PC/TC indicator 1: Diagnostic Tests
** PC/TC indicator 6: Laboratory Physician Interpretation Codes
Thanks for providing medicare modifier list. These is very helpful to new medicare members.
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