CurrentBlue Cross Blue Shield - MainePolicy G-15004

Modifiers 26 and TC, Reimbursement Policy

This reimbursement policy governs when and how Anthem Medicare Advantage (including Blue Cross Blue Shield - Maine) reimburses professional (Modifier 26) and technical (Modifier TC) components of services, and which providers/places of service may be paid. It applies to claims submission and reimbursement for affected members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 26 and TC, Reimbursement Policy

Policy CodePolicy G-15004

Change TypeNo material change

Effective DateOct 30, 2023

Next Review DateN/A

Key ActionAnthem Medicare Advantage may perform post-payment reviews of claims with Modifier 26 or 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.

NonreimbursableModifier 26/TC not allowed on E/M codes

Medicare AdvantageGeographic applicability

10/30/2023Last approval/effective date

Post-payment reviewAudit risk

Modifier Reimbursement Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Modifier reimbursement criteria

Covered when ALL of the following rules and conditions below are met:

Anthem Medicare Advantage allows reimbursement of the professional component and technical component of a global procedure or service when appended with Modifier 26 and Modifier TC unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

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

Professional component (Modifier 26): the physician or qualified healthcare professional may be reimbursed for the professional component when billed separately by appending Modifier 26.

Technical component (Modifier TC): when reported separately, the technical component is denoted by adding Modifier TC to the procedure code; only the facility may be reimbursed for the technical component when the service is performed in a facility place of service.

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

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 the service.

Modifier 26 or Modifier TC are not reimbursable when reported on Evaluation and Management (E/M) codes.

Anthem Medicare Advantage 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.

When services are performed in facility places of service (for example: Off Campus-Outpatient Hospital (19), Inpatient Hospital (21), On Campus-Outpatient Hospital (22), Emergency Room - Hospital (23), Ambulatory Surgical Center (24), Inpatient Psychiatric Facility (51), Comprehensive Inpatient Rehabilitation Facility (61)), the global procedure or technical component will not be reimbursed to a physician for those places of service; facility is eligible for TC reimbursement.

Modifiers, Reimbursement Basis, and Coding Rules

ModifiersModifierCovered

Modifier 26	Professional component — indicates physician/qualified healthcare professional rendered only the professional component of a global procedure or service
Modifier TC	Technical component — indicates technical component of a procedure; institutional charges, facility may be reimbursed for TC

Reimbursement basis — fee schedule / contracted rate, physician specialty, place of service

Reimbursement basisBased on the applicable fee schedule or contracted/negotiated rate; physician specialty; and the place of service code submitted on the claim.

Physician specialtyReimbursement varies by physician specialty as submitted on the claim.

Place of servicePayment depends on the place of service code; facility places of service affect who may be reimbursed for technical components.

Documentation and Post-Payment Review

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 may request additional documentation; if documentation is not provided after a request or notification, Anthem Medicare Advantage may recoup or recover monies previously paid on the claim.

Provider may be notified of additional documentation required for claims, subject to contractual obligations.
Failure to provide requested documentation can result in recoupment or recovery of previously paid amounts.

Term Definitions

Global Procedure definition

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 billedIf the same provider performs both components and neither Modifier 26 nor TC is appended, Anthem Medicare Advantage will reimburse the global procedure.

Reference sourcesDeveloped with consideration of CMS and Optum EncoderPro 2023 and state contracts/Medicaid.

Professional Component (Modifier 26) definition

DefinitionProfessional component (Modifier 26) is the portion of a service representing the physician's or other qualified healthcare professional's work, including interpretation and report; reported by appending Modifier 26 when billed separately.

When to useUse Modifier 26 when only the professional component of a global procedure or service is rendered and billed separately.

Billing notePhysician or qualified healthcare professional may be reimbursed only for the professional component; it is usually charged separately from inpatient hospital charges.

Technical Component (Modifier TC) definition

DefinitionTechnical component (Modifier TC) is the portion of a service that identifies provision of equipment, supplies, technical personnel, and facility costs; reported by appending Modifier TC when billed separately.

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

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

Standalone Code definition — when modifiers 26/TC should not be used

DefinitionStandalone codes represent professional-only, technical-only, or global tests where Modifier 26 or TC should not be used with the standalone code.

Modifier useDo not append Modifier 26 or Modifier TC to codes designated as standalone codes for professional-only or technical-only services.

ImplicationStandalone code billing identifies the service itself as professional-only, technical-only, or global without additional modifiers.