CurrentBlue Cross Blue Shield - MainePolicy C-20004

Modifier 26 and Modifier TC (Professional and Technical Component)

Defines reimbursement rules for billing professional (Modifier 26) and technical (Modifier TC) components of global procedures for commercial members of Blue Cross Blue Shield - Maine; governs when each component or the global procedure is reimbursable and related billing restrictions.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 26 and Modifier TC (Professional and Technical Component)

Policy CodePolicy C-20004

Change TypeNo material change

Effective DateOct 1, 2021

Next Review Date

Key ActionThe Health Plan may perform post-payment review of claims billed with Modifier 26 or Modifier TC and request documentation; failure to provide documentation may result in recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

global, professional, technicalcomponents addressed

Exhibit Afacility POS referenced

post-payment reviewaudit exposure

4policies consolidated

Reimbursement Rules for Professional and Technical Components

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Modifier 26/TC reimbursement criteria

Rules for reimbursement and restrictions for professional and technical components:

Reimbursement allowed for the professional component when a physician or other qualified health care professional appends Modifier 26 to the applicable procedure code.

Reimbursement allowed for the technical component when appended with Modifier TC, except when services are performed in a facility listed in Exhibit A — in that case only the facility may be reimbursed for the technical component and the physician may be reimbursed only for the professional component.

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

If neither Modifier 26 nor Modifier TC is present and the same provider performed both components, reimbursement of the global procedure is allowed.

When one provider reports a global procedure and a different provider reports the same procedure with Modifier 26 or Modifier TC for the same patient on the same date of service, only the first charge approved by the Health Plan will be eligible for reimbursement; subsequent charges are considered duplicate services and are not separately reimbursable.

Nonreimbursable situations

Modifier 26 or Modifier TC reported with an Evaluation and Management (E&M) code is not allowed for reimbursement.
Modifier 26 or Modifier TC should not be used when a separate stand-alone code exists that describes the professional-only, technical-only, or global test only for the diagnostic service.

Health Plan may perform post-payment review of claims submitted with Modifier 26 or Modifier TC and may request additional documentation; failure to provide requested documentation may result in recoupment or recovery of previously paid amounts.

Modifiers, Duplicate Processing, and Code Guidance

Modifiers for component billingModifierCovered

Modifier 26	Professional component — use when physician renders only the professional component of a global procedure; append to applicable procedure code.
Modifier TC	Technical component — use when billing only the technical component of a global procedure; append to applicable procedure code.

Duplicate processing rule

Duplicate processing ruleWhen one provider reports a global procedure and a different provider reports the same procedure with Modifier 26 or Modifier TC for the same patient on the same date, only the first charge approved by the Health Plan is eligible for reimbursement; subsequent processed charges are considered duplicates and are not separately reimbursable.

ScopeApplies when global and component (26 or TC) services are reported for the same patient on the same date of service.

Effect on subsequent claimsSubsequent charges processed after the first approved charge will be considered duplicate services and not eligible for separate reimbursement.

Documentation, Review, and Billing Responsibilities

Documentation Required

Post-payment review may require documentation; failure may lead to recoupment

The Health Plan 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, the Health Plan may recoup or recover monies previously paid on the claim.

Health Plan 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 previously paid amounts.

Key Terms and Definitions

Global Procedure

DefinitionGlobal Procedure = Represents both the professional and technical component as a complete procedure or service; identified by reporting the eligible procedure without Modifier 26 or TC.

Reimbursement when same provider performs both componentsIf the same physician or qualified health care professional performed both professional and technical components and no modifiers are present, reimbursement of the global procedure is allowed.

Interaction with component billingIf components are billed separately (26 or TC), global procedure should not be reported without consideration of duplicate processing rules.

Professional Component (Modifier 26)

DefinitionProfessional Component (Modifier 26) = Represents the supervision and interpretation portion of a service or procedure and the preparation of a written report; denotes the professional portion when billed separately by adding Modifier 26 to the applicable procedure code.

When to useUse Modifier 26 when a physician or other qualified health care professional renders only the professional component of a global procedure or service.

LimitationsModifier 26 is not allowed with Evaluation & Management (E&M) codes and should not be used when a stand-alone code describes the professional component.

Technical Component (Modifier TC)

DefinitionTechnical Component (Modifier TC) = Represents the technical personnel, equipment, supplies and institutional charges of a service or procedure; denotes the technical portion when billed separately by adding Modifier TC to the applicable procedure code.

Facility billing restrictionServices performed in a facility listed in Exhibit A will not be reimbursed for the global procedure or the technical component to the physician; only the facility may be reimbursed for the technical component and the physician may be reimbursed only for the professional component.

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

Stand-alone Code

DefinitionStand‑alone Code = Describes the professional component only, technical component only, or global test only of a selected diagnostic test; Modifier 26 and TC should not be used with a stand‑alone code.

Billing implicationDo not append Modifier 26 or TC when a separate stand‑alone code exists that describes the professional‑only, technical‑only, or global test only service.

Nonreimbursable contextUse of Modifier 26 or TC with a stand‑alone code may result in claim denial and is not allowed by the Health Plan.