CurrentAnthemPolicy G-15004

Modifiers 26 and TC (professional and technical components) reimbursement

Defines Anthem Medicare Advantage reimbursement policy for reporting and payment of professional (Modifier 26) and technical (Modifier TC) components of global procedures for affected providers and facilities under the listed Medicare Advantage states.

Policy Summary

PayerAnthem

PolicyModifiers 26 and TC (professional and technical components) reimbursement

Policy CodePolicy G-15004

Change TypeNo material change

Effective DateOct 30, 2023

Next Review Date

Key ActionAnthem may perform post-payment review of claims submitted with Modifier 26 or TC and may request additional documentation; failure to provide documentation may lead to recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Advantage — multiple statesjurisdictions

ProhibitedE/M codes

Facility retainsTC reimbursement

When same practitionerGlobal allowed

10/30/2023effective

Coverage Criteria for Modifiers 26 and TC

Anthem Medicare Advantage reimbursement stance for professional and technical components is as follows.

Anthem allows reimbursement of professional (Modifier 26) and technical (Modifier TC) components when appended to a global procedure unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Reimbursement is determined by the applicable fee schedule or contracted/negotiated rate, physician specialty, and the place of service code submitted on the claim.

Professional component billing: when only the professional component is rendered, append Modifier 26 to the procedure code to report and bill that professional component.

Technical component billing and facility restriction: when reported separately append Modifier TC to the procedure code; only the facility may be reimbursed for the technical component when services are performed in a facility place of service, and physicians in those facility places of service will not be reimbursed for the global procedure or the technical component. Portable x-ray suppliers should bill only for the technical component (Modifier TC).

Policy Summary

PayerAnthem

PolicyModifiers 26 and TC (professional and technical components) reimbursement

Policy CodePolicy G-15004

Change TypeNo material change

Effective DateOct 30, 2023

Next Review Date

Key ActionAnthem may perform post-payment review of claims submitted with Modifier 26 or TC and may request additional documentation; failure to provide documentation may lead to recoupment.

SourceLink

On This Page

Post-payment Review and Documentation Requests

Documentation Required

Post-payment review and documentation requests

Anthem Medicare Advantage reserves the right to perform post-payment review of claims submitted with Modifier 26 or Modifier TC and may request additional documentation; if documentation is not provided following the request or notification, Anthem Medicare Advantage may recoup or recover monies previously paid on the claim.

Anthem may request additional documentation or notify the provider of additional documentation required for claims, subject to contractual obligations.
Failure to provide requested documentation may result in recoupment or recovery of payments.

Definitions

Global Procedure

DefinitionA complete procedure or service that represents both the professional and technical components, reported without Modifier 26 or Modifier TC.

ReportingIdentified by reporting the eligible procedure code without appending Modifier 26 or Modifier TC.

Reimbursement ruleIf neither Modifier 26 nor Modifier TC is present and the same practitioner performed both components, Anthem Medicare Advantage will reimburse the global procedure.

Professional Component (Modifier 26)

DefinitionPortion of a charge that represents the physician's or other practitioner's work in providing the service, including interpretation and report of the procedure.

ReportingWhen rendered separately, append Modifier 26 to the applicable procedure code to indicate only the professional component was performed.

Billing guidanceThis component is usually billed separately from inpatient hospital charges and should be billed by the professional when only the professional component is rendered.

Technical Component (Modifier TC)

DefinitionPortion of a healthcare service that identifies the provision of equipment, supplies, technical personnel, and institutional costs attendant to performance of the procedure.

ReportingWhen reported separately, append Modifier TC to the applicable procedure code to indicate only the technical component was performed.

Facility reimbursementOnly the facility may be reimbursed for the technical component when services are performed in a facility place of service; physicians in those facility places will not be reimbursed for the global procedure or the TC.

Portable x-ray suppliersPortable x-ray suppliers should bill only for the technical component by appending Modifier TC.

Standalone Code

DefinitionCodes that represent only the professional component, only the technical component, or the global test itself; these codes should be reported as standalone codes.

Modifier guidanceModifier 26 or Modifier TC should not be used with standalone codes.

PurposeUsed to identify tests or services that are inherently only one component (professional or technical) or already represent the global service.

OpenPayer

Modifiers 26 and TC (professional and technical components) reimbursement

Coverage Criteria for Modifiers 26 and TC

Modifier Coding and Status

Post-payment Review and Documentation Requests

Definitions

Modifier 26	Professional component — reported when only the professional component of a global procedure is performed
Modifier TC	Technical component — reported when only the technical component of a global procedure is performed