CurrentBlue Cross Blue Shield - MainePolicy G-15004

Modifiers 26 and TC (professional and technical components)

Reimbursement policy governing separate billing and reimbursement of the professional (Modifier 26) and technical (Modifier TC) components of global procedures for Anthem Medicare Advantage; affects providers submitting claims for services to Anthem Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 26 and TC (professional and technical components)

Policy CodePolicy G-15004

Change TypeNon-material revisions

Effective DateOct 30, 2023

Next Review DateN/A

Key ActionProvide requested documentation for claims with Modifier 26 or TC upon post-payment review to avoid recoupment.

SourceLink

POLICY UPDATE CHANGES

Removed 'Professional and Technical Component' from policy title and updated comments in Related Coding and Definitions sections.

Updated Modifiers 26 and TC in Definitions section.

G-15004policy identifier

2023-10-30effective / last approval date

Anthem MAapplicable program

E/M nonreimbmodifier restriction

Coverage Criteria for Modifiers 26 and TC

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Modifiers 26/TC coverage criteria

Covered when ALL of the following conditions are met:

ALL of the following

Anthem Medicare Advantage allows reimbursement of the professional (Modifier 26) and technical (Modifier TC) components of a global procedure when appended to the applicable procedure code unless provider, state, federal, or CMS contracts or requirements indicate otherwise.
Exception: In the absence of Modifier TC and Modifier 26, Anthem Medicare Advantage will allow reimbursement of the global procedure if the same physician or other qualified healthcare professional performed both the professional and technical components of that service.
When services or procedures billed by a physician or other qualified healthcare professional are performed in facility places of service (for example: outpatient hospital, inpatient hospital, on-campus outpatient hospital, emergency room), the global procedure or the technical component will not be reimbursed to the physician; only the facility may be reimbursed for the technical component.
Portable x-ray suppliers should bill only for the technical component by appending Modifier TC.
Modifier 26 and Modifier TC must not be reported on Evaluation and Management (E/M) codes; such reporting is nonreimbursable.

Reimbursement is based on the applicable fee schedule or contracted rate and physician specialty and place of service submitted on the claim.

Coding and Place of Service Rules

ModifiersmixedCovered

Modifier 26	Professional component appended to procedure code when only physician/professional component is provided.
Modifier TC	Technical component appended to procedure code when only technical/institutional component is provided.

Nonreimbursable UsagemixedNot Covered

Modifier 26 with E/M codes	Modifier 26 must not be used with Evaluation and Management (E/M) codes; such usage is nonreimbursable.
Modifier TC with E/M codes	Modifier TC must not be used with Evaluation and Management (E/M) codes; such usage is nonreimbursable.

Facility Technical ComponentmixedNot Covered

TC when performed in facility POS

Technical component billed by physician for services performed in specified facility places of service will not be reimbursed to the physician; only the facility may be reimbursed for the technical component.

Portable X-ray SuppliersmixedCovered

Modifier TC (portable x-ray suppliers)

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

Facility POS technical component reimbursement

Facility places of service where physicians are not reimbursed for TCWhen services are performed in facility places of service (e.g., outpatient hospital, inpatient hospital, emergency room, ambulatory surgical center, inpatient psychiatric, rehabilitation facilities), the technical component will not be reimbursed to physicians; only the facility may be reimbursed for the technical component.

Physician reimbursement limitationPhysicians may be reimbursed only for the professional component when service occurs in a facility POS; physicians should arrange with the facility for reimbursement of any technical components they perform.

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

Provider Responsibilities and Reviews

Documentation Required

Post‑payment review and documentation requests

Anthem Medicare Advantage may perform post‑payment review of claims submitted with Modifier 26 or Modifier TC and request additional documentation; if the provider does not provide the requested documentation, Anthem Medicare Advantage may recoup previously paid amounts.

Anthem Medicare Advantage reserves the right to perform post‑payment review of claims submitted with Modifier 26 or Modifier TC.
Anthem Medicare Advantage may request additional documentation or notify the provider of additional documentation required for claims, subject to contractual obligations.
Failure to provide documentation after a request or notification may result in recoupment or recovery of monies previously paid on the claim.

Definitions

Global Procedure

DefinitionGlobal Procedure represents both the professional and technical components as a complete procedure or service and is identified by reporting the eligible procedure without Modifier 26 or TC.

When reimbursed as globalIf the same physician performs both components and neither Modifier 26 nor TC is present, Anthem Medicare Advantage will reimburse the global procedure.

Reimbursement basisReimbursement is based on the applicable fee schedule or contracted rate and physician specialty and place of service submitted on the claim.

Professional Component (Modifier 26)

What it denotesProfessional component indicates when a physician or other qualified healthcare professional renders only the professional component of a global procedure; reported by appending Modifier 26 to the procedure code.

What it includesPortion of the charge representing the physician's work in providing the service, including interpretation and report of the procedure; may be billed separately from institutional charges.

Usage guidanceModifier 26 should not be used with standalone codes that already represent only the professional or technical component; not allowed on Evaluation and Management (E/M) codes.

Technical Component (Modifier TC)

What it denotesTechnical component identifies provision of equipment, supplies, technical personnel, and institutional costs attendant to performance of the procedure; reported by appending Modifier TC to the procedure code.

Institutional billingTechnical component charges are institutional charges and are not billed separately by physicians when services occur in defined facility places of service; only the facility is reimbursed for the TC in those settings.

Portable x-ray suppliersPortable x-ray suppliers should bill only for the technical component and should utilize Modifier TC; their charge data are used to build customary and prevailing profiles.