Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Modifiers 26 (Professional Component) and TC (Technical Component)

Policy #:

MA03.011m

Policy

This policy applies to professional providers billing professional or outpatient facility claims, for members enrolled in all Company products.

The Company applies the following Medicare Physician Fee Schedule Database indicators for professional component (PC) and technical component (TC) services to procedure codes, as reported by professional providers, to determine the appropriate reporting of Modifier 26 (professional component) and Modifier TC (technical component):

0 = Physician Service Codes: This indicator identifies procedure codes that describe physician services (e.g., office visits, surgical procedures). The concepts of professional and technical components do not apply to procedure codes with a “0” indicator, as these services cannot be split into professional and technical components.

All professional claims received with procedure codes that carry a “0” indicator appended with either Modifier 26 or Modifier TC will be denied as: Invalid procedure code/modifier combination.

1 = Diagnostic Tests or Radiology Services: This indicator identifies procedure codes that describe diagnostic tests (e.g., pulmonary function tests) or therapeutic radiology services (e.g., radiation therapy), that have both a professional and a technical component.

SERVICES PERFORMED IN A FACILITY SETTING:

Professional claims received for services performed in facility settings with procedure codes that carry a “1” indicator must be appended with Modifier 26 to identify the service as a professional component of the diagnostic test or radiology service performed. Professional claims received without Modifier 26 appended to the procedure code will be denied as: Modifier 26 required for this place of service. (The technical component of this service is provided by the facility.)

Procedure codes that carry a “1” indicator are only eligible for reimbursement consideration to professional providers in facility settings as professional component services.

Professional claims received for services performed in facility settings with procedure codes that carry a “1” indicator appended with Modifier TC will be denied for reimbursement consideration. Professional claims received with Modifier TC appended to the procedure code will be denied as: Procedure code modifier cannot be reported in this place of service. (The technical component of this service is provided by the facility.)

SERVICES PERFORMED IN A NONFACILITY SETTING:

Professional claims received for services performed in nonfacility settings with procedure codes that carry a 1 indicator appended with Modifier 26 will be processed as professional component services. Professional claims received without either the Modifier 26 or Modifier TC appended to the procedure code will be processed as a global service.
Professional claims received for services performed in nonfacility settings with procedure codes that carry a 1 indicator appended with Modifier TC will be processed as technical component services. However:

Procedure codes that carry a 1 indicator appended with Modifier TC should only be reported by the billing provider who owns the equipment and when a different professional provider performs the professional component service.

When the billing provider performs both the professional and the technical components (i.e., the global service) in the nonfacility setting, the procedure code should not be reported with Modifier 26 and/or Modifier TC.
Professional claims received without either Modifier 26 or Modifier TC appended to the procedure code will be processed as a global service.

2 = Professional Component Only: This indicator identifies stand-alone professional component procedure codes that describe only the professional provider work portion of selected diagnostic tests for which there is also an associated stand-alone technical component procedure code and one that describes the global test. Therefore, procedure codes that carry a 2 indicator do not require and should not be appended with either Modifier 26 or Modifier TC.

Professional claims received with procedure codes that carry a 2 indicator appended with either Modifier 26 or Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

3 = Technical Component Only: This indicator identifies stand-alone technical component procedure codes that describe only the technical component of selected diagnostic tests for which there may or may not also be an associated professional component stand-alone code and one that describes the global test. Therefore, procedure codes that carry a 3 indicator do not require and should not be appended with either Modifier 26 or Modifier TC.

Professional claims received with procedure codes that carry a 3 indicator appended with either Modifier 26 or Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

4 = Global Test Only: This indicator identifies global diagnostic stand-alone procedure codes for which there are associated professional component-only and technical component-only stand-alone codes. Therefore, procedure codes that carry a 4 indicator do not require and should not be reported with either Modifier 26 or Modifier TC.

Professional claims received with procedure codes that carry a 4 indicator appended with either Modifier 26 or Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

5 = Incident to Codes: This indicator identifies procedure codes that describe services that are incidental to a professional provider's service or a service that is provided by auxiliary personnel employed by a professional provider and performed under the direct supervision of the employing provider. Therefore, procedure codes that carry a 5 indicator do not require and should not be reported with either Modifier 26 or Modifier TC.

Professional claims received with procedure codes that carry a 5 indicator appended with Modifier 26 and/or Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

6 = Laboratory Physician Interpretation Codes: This indicator identifies certain clinical laboratory codes for which separate reimbursement may be considered for the interpretations of the corresponding tests by professional providers. Procedure codes with the 6 indicator are eligible to be reported with Modifier 26 to identify the interpretation of these clinical laboratory tests. However, these procedure codes should not be reported with Modifier TC, as the actual performance of the test is the technical component and is considered for reimbursement under the laboratory fee schedule. Procedure codes that carry a 6 indicator do not require and should not be appended with Modifier TC.

SERVICES PERFORMED IN A FACILITY SETTING:

Professional claims received for services performed in facility settings with procedure codes that carry a 6 indicator appended with Modifier 26 will be processed as professional component services.

Professional claims received without Modifier 26 appended to the procedure code that carry a 6 indicator will be denied as: Modifier 26 required for this place of service.
Procedure codes that carry a 6 indicator are only eligible to be reported by professional providers as a professional service in a facility setting.

Professional claims received for technical component services performed in facility settings with procedure codes that carry a 6 indicator appended with Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

SERVICES PERFORMED IN A NONFACILITY SETTING:

Professional claims received for services performed in nonfacility settings with procedure codes that carry a 6 indicator appended with Modifier 26 will be processed as physician interpretation services.
Professional claims received for services performed in nonfacility settings with procedure codes that carry a 6 indicator not appended with Modifier 26 will be processed as clinical laboratory tests.
Professional claims received for technical component services performed in nonfacility settings with procedure codes that carry a 6 indicator appended with Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

7 = Physical/Occupational Therapy Service: This indicator identifies procedure codes that are used to report rehabilitation services. The concepts of professional and technical components do not apply to these codes, as these services cannot be split into professional and technical components. Therefore, procedure codes that carry a 7 indicator should not be reported with Modifier 26 or Modifier TC.

Professional claims received with procedure codes that carry a 7 indicator appended with either Modifier 26 or Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

8 = Physician Interpretation Codes: This indicator identifies the professional component of clinical laboratory codes for which separate reimbursement may be considered only if the professional provider interprets an abnormal smear in a facility setting. Therefore, procedure codes that carry an 8 indicator do not require and should not be reported with Modifier 26 or Modifier TC.

Professional claims received with a procedure code that carry an 8 indicator appended with either Modifier 26 or Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

9 = Concept Does Not Apply Codes: This indicator identifies procedure codes for which the concepts of professional and technical components do not apply. Therefore, procedure codes that carry a 9 indicator should not be reported with Modifier 26 or Modifier TC.

Professional claims received with procedure codes that carry a 9 indicator appended with either Modifier 26 or Modifier TC will be denied for reimbursement consideration as: Invalid procedure code/modifier combination.

The place of service code assigned by the professional provider who interprets the diagnostic service shall be the setting in which the individual received the service.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Claims submitted with Modifier 26 and TC are subject to post-payment clinical review and potential retractions for inappropriate use.

ADDITIONAL INFORMATION AND REQUIREMENTS

The documentation in the medical record must support the work (i.e., professional component-service, technical component-service, or both [global]) reported by the professional provider. The professional component includes and the medical record must reflect the interpretation, analysis, and a detailed signed written report of the results of the procedure or service.

Guidelines

This policy is consistent with Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services' (CMS) reporting requirements.

ADDITIONAL CLAIMS INFORMATION

Medical records, reports, or other documentation should not be appended to the claim unless specifically required and/or requested by the Company.
The following claim denials received by participating/network providers in association with the incorrect reporting/nonreporting of Modifiers 26 and/or TC are not billable to members:
- Modifier 26 required for this place of service
- Invalid procedure code/modifier combination
- Procedure code modifier cannot be reported in this place of service

Description

Certain procedures involve a combination of a professional component and a technical component. For example, the professional component of a radiology service includes the professional provider's supervision of the radiology technician and the interpretation by the professional provider of the radiology service. The technical component of the radiology service includes the work of the radiology technician and the overhead costs associated with the radiology service. Other procedures may consist of either a professional component only (e.g., office visits) or a technical component only (e.g., flow cytometry codes) indicated.

The Centers for Medicare & Medicaid Services (CMS) maintains the Medicare Physician Fee Schedule Database indicators for professional components (PC) and technical components (TC). These indicators establish the appropriate reporting of procedure codes for component services (PC/TC). When it is appropriate to report PC or TC services, the corresponding modifier (Modifier 26 [professional component] or Modifier TC [technical component]) is appended to the procedure code.

The professional component (PC) is the portion of the procedure or service performed by a professional provider, which includes the interpretation, analysis, and a detailed signed written report of the results of the procedure or service.

The technical component (TC) comprises the portion of the procedure or service performed by a technician or other non-provider personnel and the equipment used for the procedure or service and, in most cases, the ownership of the equipment used for the procedure or service. The TC does not involve any direct physician care.

Global service refers to procedure codes that include both the professional and technical components. These procedure codes, when reported without the modifier for the professional component (26) or the modifier for the technical component (TC), are considered to be global services. Alternatively, when these procedure codes are reported with either Modifier (26 or TC), they are considered to be reported for the corresponding component, only. Global service codes are never reported with both modifiers to indicate that the global service has been performed. The term global services does not refer to a reimbursement mechanism or to a time period associated with a surgical procedure.

References

Centers for Medicare and Medicaid Services. Claims Processing Manual: Chapter 23 - Fee Schedule Administration and Coding Requirements. 09/18/2020. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. Accessed: November 10, 2020.

American Medical Association (AMA). CPT® 2018 Professional Edition: Spiralbound.dition: Current Procedural Terminology (Current Procedural Terminology, Professional Ed. (Spiral); 2017.

Centers for Medicare & Medicare Services (CMS). PFS Relative Value Files http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html.

Optum360. 2019 Understanding Modifiers: Softbound.

Coding

CPT Procedure Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes and Healthcare Common procedure Coding System (HCPCS) within the PCTC IND column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes and Healthcare Common procedure Coding System (HCPCS) within the PCTC IND column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

26 Professional component
TC Technical component

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA03.011m:

01/02/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2024.

Revisions From MA03.011l:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
07/01/2023	This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2023.

Revisions From MA03.011k:

01/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2023.

Revisions From MA03.011j:

09/07/2022	This version of the policy will become effective 09/07/2022. This policy has been reissued in accordance with the Company's annual review process.
07/01/2022	This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2022.

Revisions From MA03.011i:

04/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2022.

Revisions From MA03.011h:

07/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2021.

Revisions From MA03.011g:

01/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021.

Revisions From MA03.011f:

12/21/2020

This policy will become effective on 12/21/2020. The adoptable source for this policy is CMS. The references were updated accordingly. The policy was updated to be consistent with current template wording and format.

Revisions From MA03.011e:

01/01/2020

This version of the policy will become effective 01/01/2020. As a result of the 01/01/2020 Annual Code Update, the following codes have been added to this policy business requirements to accommodate system setup. This policy document does not contain procedure codes.

The following CPT and HCPCS codes have been deleted from this policy requirements: 0482T, 74241, 74245, 74247, 74249, 74260, 76930, 78205, 78206, 78320, 78607, 78647, 78710, 78805, 78806, 78807, 95827, 95950, 95951, 95953, 95956, and G0365

The following CPT codes have been added to this policy requirements: 74221, 74248, 78429, 78430, 78431, 78432, 78433, 78434, 78830, 78831, 78832, 78835, 92549, 93985, 93986

Revisions From MA03.011d:

01/01/2019

This version of the policy will become effective 01/01/2019. As a result of the 01/01/2019 Annual Code Update, the following codes have been added to this policy business requirements to accommodate system setup. This policy document does not contain procedure codes.

The following CPT codes have been deleted from this policy requirements: 0159T, 76001, 77058, 77059, 78270, 78271, 78272, 92275

The following CPT codes have been added to this policy requirements: 0506T, 0507T, 0508T, 0509T, 0521T, 0522T, 0528T, 0529T, 0533T, 0534T, 0535T, 0536T, 76391, 76978, 76979, 76981, 76982, 76983, 77046, 77047, 77048, 77049, 92273, 92274

Revisions From MA03.011c:

01/01/2018

Revised policy number MA03.011c was issued as a result of annual policy. The References were updated accordingly. The adoptable source for this policy is CMS.

Revisions From MA03.011b:

01/01/2017

Revised policy number 03.00.20g was issued as a result of annual policy. The References were updated accordingly. The adoptable source for this policy is CMS.

Revisions From MA03.011a:

11/02/2015

This version of the policy will become effective 11/1/2015.

Revised policy MA03.011a was issued as a result of annual policy review. The References were updated accordingly. The policy was updated to be consistent with current template wording and format.

Revisions From MA03.011:

01/01/2015

This is a new policy.

Version Effective Date:

1/2/2024

Version Issued Date:

1/5/2024

Version Reissued Date: