CurrentColorado Rocky Mountain Health PlansPolicy 2026R9031A

CMS 1500 Professional/Technical (PC/TC) Reimbursement Policy

Defines UnitedHealthcare Medicare Advantage reimbursement methodology for services billed on the CMS-1500 (professional claims), including handling of CMS PC/TC indicators, professional/technical splits, place-of-service rules, duplicate/repeat submissions, modifier use, and documentation requirements for radiology interpretations. Applies to all Medicare Advantage products and network physicians and other qualified health care professionals submitting CMS-1500 claims.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 Professional/Technical (PC/TC) Reimbursement Policy

Policy CodePolicy 2026R9031A

Change TypeRevised and Added attachmentsadministrative updates

Effective Date

Next Review Date

Key ActionWhen billing radiology interpretation with modifier 26 on the same date as an E/M and requesting separate reimbursement, submit a distinctly identifiable signed written radiology interpretation report per the Radiological Codes Requiring Attached Report.

SourceLink

POLICY UPDATE CHANGES

Attachments: Updated Gap Fill Codes list (4/22/2026).

Reimbursement Guidelines: Remove POS 55,57 (4/3/2025).

Attachments: Added Radiological Codes Requiring Attachment (10/1/2024).

Attachments: Replaced URL with embedded document (5/1/2024).

Questions and Answers: Added Q&A #6 and #7 (10/1/2024).

0-9CMS PC/TC indicator values referenced

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Place-of-service codes treated as facility on CMS-1500

Gap Fill updatedAttachment changed in latest revision

QuarterlyPC/TC percentage split updates

Policy Snapshot

This document is a UnitedHealthcare Medicare Advantage reimbursement policy titled CMS 1500 Professional/Technical (PC/TC) Reimbursement Policy (policy number 2026R9031A). It is a policy-type document applicable to UnitedHealthcare Medicare Advantage products and network physicians and other qualified health care professionals submitting professional claims on the CMS-1500 form. The policy is CURRENT and describes the methodology used to determine reimbursement for CPT and HCPCS codes based on CMS NPFS PC/TC indicators, including professional/technical splits, modifier usage, place-of-service rules, duplicate/repeat submissions, and documentation expectations for radiology interpretations.

This policy applies to all Medicare Advantage products for services reported on the CMS-1500 (or electronic equivalent) and outlines responsibilities for accurate claim submission, the coding and reimbursement framework used, and the sources UnitedHealthcare references when applying the PC/TC concept to professional claims.

Quick facts

Policy number2026R9031A

Last review2026-04-22

Material change in this versionYes — policy has material changes (see Changes).

Place-of-service codes treated as facility on CMS-1500 (count)12 POS values

When Professional Component (PC) Is Reimbursed or Denied

Eligibility for Professional Component reimbursement when service furnished in facility POS

Conditions under which UnitedHealthcare will reimburse the interpreting physician/QHP for the Professional Component when services are furnished in a facility POS.

ALL of the following

Service reported on CMS-1500 with a facility POS (19,21,22,23,24,26,31,34,51,52,56,61).
AND one of the following code indicator/modifier conditions is met: (a) CMS PC/TC Indicator 1 reported with modifier 26; (b) CMS PC/TC Indicator 2 reported without modifier 26 or TC; (c) CMS PC/TC Indicator 6 reported with modifier 26; (d) CMS PC/TC Indicator 8 reported without modifier 26.

ALL of the following

(Operational note) Facility POS values are those listed in the policy and must be reported on the CMS-1500 to be considered for Professional Component reimbursement.

Codes and Coding Rules

Drug administration codes not reimbursed in POS 24CPTNot Covered

96360-96379, 96401-96425, 96521-96523

Drug administration codes considered included in facility payment when reported in POS 24; not reimbursed to physician/QHP in POS 24.

PC/TC Indicator 8 exampleCPTNot Covered

85060

Physician interpretation code (PC/TC Indicator 8) — not reimbursed when reported with POS other than 21 (inpatient hospital).

The policy includes multiple attachments and lists that support its administrative and billing rules (for example, modifier lists, gap-fill codes, and radiological codes requiring attached reports). The attachments are named in the policy (e.g., "Professional Technical Component Policy Modifiers," "Gap Fill Codes (updated lists)," and "Radiological Codes Requiring Attached Report").

Notably, the policy calls out Gap Fill Codes and a list of Radiological Codes Requiring an Attached Report; the Gap Fill Codes list was most recently updated on 4/22/2026 and the Radiological Codes list was added 10/1/2024. Content writers should reference the exact attachment names in the policy when including or linking supporting documents rather than reproducing those lists within narrative sections.

Billing, Documentation, and Operational Requirements

Billing Rule

Report correct place of service and modifiers

Report facility place-of-service values on CMS-1500 when services are furnished in a facility and append modifiers only as allowed by the code's PC/TC indicator. Facility POS values to report are: 19, 21, 22, 23, 24, 26, 31, 34, 51, 52, 56, 61. Use modifier 26 for Professional Component and modifier TC for Technical Component where the CMS PC/TC indicator permits; use repeat procedure modifiers 76 or 77 for subsequent procedures and use distinct service modifiers 59, XE, XP, XS, XU or 91 when required for separate consideration per the policy.

Facility POS values: 19, 21, 22, 23, 24, 26, 31, 34, 51, 52, 56, 61
Example component modifiers: 26 (Professional Component), TC (Technical Component)
Example repeat/duplicate modifiers: 76, 77 (repeat procedures); 59, XE, XP, XS, XU, 91 (distinct/separate services)

Key Terms

Definitions

Allowable AmountDollar amount eligible for reimbursement to the physician or QHP on the claim (contracted rate, reasonable charge, or billed charges as applicable).

Global ServiceService that includes both a Professional Component and a Technical Component; billed globally when no modifier is attached.

Professional Component (PC)Physician/QHP work portion (supervision and interpretation) of a procedure; identified by modifier 26 or stand-alone PC codes.

Technical Component (TC)Performance (technician/equipment/facility) portion of a procedure; identified by modifier TC or stand-alone TC codes.

Gap CodeCPT/HCPCS code for which CMS does not develop RVUs; may be assigned PC/TC Indicator 1 and require gap-fill methodology.

Duplicate or Repeat ServicesIdentical CPT/HCPCS codes with PC/TC indicator 1,2,3,4,6 or 8 submitted by same provider for same patient and same date of service on separate claim lines or different claims, regardless of MUE value.

Clinical and Administrative Background

This policy provides clinical and administrative context for handling professional and technical components of services billed on the CMS-1500. It explains UnitedHealthcare's use of CMS PC/TC indicators to determine eligibility for separate Professional Component (PC) and Technical Component (TC) reimbursement, when modifier 26 or TC are appropriate, and how the insurer applies percentage splits derived from CMS RBRVS data (updated quarterly).

The document clarifies that when services are furnished in facility place-of-service codes identified on the CMS-1500 as facility POS, UnitedHealthcare will generally reimburse only the Professional Component to the interpreting physician/QHP while the facility is reimbursed for the Technical Component, and it outlines exceptions (for example, certain PC/TC indicators and the conditions for separate radiology interpretation reimbursement when a signed written report is submitted).

Policy History & Recent Changes

2026-04-22Attachments updatedLatest

Attachments section: Updated Gap Fill Codes list; history entries before 4/22/2024 archived.

2025-04-03Reimbursement guidelines revised

Reimbursement Guidelines: Removed POS 55 and 57; history entries before 4/3/2025 archived.

2025-01-26Attachments updated

Attachments section: Updated Gap Fill Codes list.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 Professional/Technical (PC/TC) Reimbursement Policy

Policy CodePolicy 2026R9031A

Change TypeRevised and Added attachmentsadministrative updates

Effective Date

Next Review Date

SourceLink

On This Page

ALL of the following

(Reference) UnitedHealthcare uses CMS PC/TC indicators per NPFS to determine professional/technical eligibility and PC/TC Indicator definitions described in policy.

Non-reimbursable components when furnished in facility POS

Services UnitedHealthcare will not reimburse physicians/QHPs for when furnished in a facility POS.

ANY of the following

PC/TC Indicator 5 (Incident To) codes — not reimbursed to physicians/QHPs in facility POS.
PC/TC Indicator 4 (Stand-alone Global Test Only Codes) — not reimbursed to physicians/QHPs in facility POS.
PC/TC Indicator 3 or 9 laboratory services — not reimbursable to reference/non-reference labs in facility POS.
PC/TC Indicator 7 (private therapy services) — not reimbursed to physicians/QHPs when provided in facility POS.

ANY of the following

(Note) Policy follows CMS NPFS indicators to determine which services do not qualify for Professional Component reimbursement when furnished in a facility POS.

Duplicate/Repeat Services reimbursement rules (same provider, same DOS)

When identical CPT/HCPCS codes are submitted by the same provider for same patient/date, rules for separate consideration.

ANY of the following

First-in, first-out claim payment methodology: only the first received claim considered for reimbursement unless subsequent lines have appropriate modifiers.
Global service (PC/TC 1) or stand-alone (PC/TC 2,3,4) billed more than once — separate reimbursement only if appropriate modifier appended; otherwise subsequent services denied.
If same provider reports PC and TC separately for same PC/TC 1 service, both may be reimbursed unless other policy sections apply (i.e., separate consideration given when 26 and TC reported separately).
When the same PC/TC 6 or 8 service is reported more than once by the same provider, separate consideration will only be given if modifiers 59, XE, XP, XS, XU or 91 are appended; otherwise subsequent services denied.
When a PC/TC 4 service is billed with a PC/TC 2 or 3 service for the same DOS and provider, the second/subsequent service will be denied unless billed with an appropriate modifier.

ANY of the following

(Modifier guidance) Use modifiers 76/77 for repeat procedures as appropriate; use 59/XE/XP/XS/XU/91 to indicate distinct/repeat services for duplicate editing as specified.

Radiology professional component with same-day E/M

Conditions under which radiology interpretation (modifier 26) may be reimbursed in addition to an E/M on same day.

ALL of the following

Same Individual Physician or Other QHP performed both services on the same date of service for the same patient (same NPI).
By default, radiology interpretation (modifier 26) is considered included in the E/M and not separately reimbursed, except for radiologic codes describing fluoroscopic or ultrasonic guidance for placement of a needle, catheter, or tube and other exceptions.
If the provider seeks separate reimbursement for a radiology interpretation billed with modifier 26, a distinctly identifiable signed written radiology interpretation report must be submitted (see Radiological Codes Requiring Attached Report).
Appending modifiers 59, XE, XP, XS or XU in addition to 26 does not waive the requirement for the written radiology report; documentation must still be submitted for separate reimbursement.

ALL of the following

(Documentation guidance) ACR-recommended content (procedures/materials, findings, impression) should be included in the written report when seeking separate reimbursement.

Documentation Required

Attach signed radiology interpretation for separate reimbursement

When submitting a radiology interpretation appended with modifier 26 on the same date as an E/M and seeking separate reimbursement, include a distinctly identifiable signed written radiology interpretation report as required by the Radiological Codes Requiring Attached Report attachment; modifier 59 (or XE/XP/XS/XU/91) appended to 26 does not waive the signed report requirement.

Submit a distinctly identifiable signed written radiology interpretation report when billing 26 with a same-day E/M
Appending 59, XE, XP, XS, XU or 91 in addition to 26 does not waive the report requirement
See attachment: Radiological Codes Requiring Attached Report for codes that require the attached report

Billing Rule

Gap codes and gap-fill methodology

For codes CMS identifies as Gap Codes (PC/TC Indicator 1 without CMS RVUs), UnitedHealthcare uses Optum The Essential RBRVS first-quarter relative values for gap-fill; Gap Codes lacking RVUs or gap-fill data listed in the attachments may be allowed at 100% of the Allowable Amount for both PC and TC. See the Gap Fill Codes attachment for the updated lists.

Gap-fill source: Optum The Essential RBRVS (first quarter update of the current calendar year)
Some Gap Codes without RVUs or gap-fill data are allowed at 100% of the Allowable Amount for both PC and TC
Attachment: Gap Fill Codes (updated lists; most recent update 4/22/2026)

Billing Rule

Duplicate/Repeat claim handling

UnitedHealthcare applies a first-in, first-out claim payment methodology for duplicate or repeat services; only the first received claim is considered for reimbursement unless subsequent claims include the appropriate modifier, otherwise second and subsequent submissions will be denied.

First-in, first-out: the earliest received claim for the identical code/date/provider is considered for payment
Subsequent claims require appropriate modifiers (e.g., 76/77 for repeat procedures; 59/XE/XP/XS/XU/91 for distinct services) or they will be denied

Same Individual Physician or Other Qualified Health Care ProfessionalSame individual rendering services reporting the same NPI number.

2024-10-01Attachments added / Q&A updated

Attachments: Added Radiological Codes Requiring Attachment and Questions & Answers updated with Q&A #6 and #7; history entries prior to 10/1/2022 archived.

2024-05-01Attachments revised

Attachments: Replaced URL with embedded document; history entries prior to 5/1/2022 archived.

2017-12-13Policy approval

Policy approved by the Reimbursement Policy Oversight Committee.

Summary of changes

revisedAttachments: Updated Gap Fill Codes list (4/22/2026). is_material: true

revisedReimbursement Guidelines: Remove POS 55,57 (4/3/2025). is_material: true

addedAttachments: Added Radiological Codes Requiring Attachment (10/1/2024). is_material: true

revisedAttachments: Replaced URL with embedded document (5/1/2024). is_material: false

clarifiedQuestions and Answers: Added Q&A #6 and #7 (10/1/2024). is_material: false

CMS 1500 Professional/Technical (PC/TC) Reimbursement Policy

Policy Snapshot

When Professional Component (PC) Is Reimbursed or Denied

Codes and Coding Rules

Billing, Documentation, and Operational Requirements

Key Terms

Clinical and Administrative Background

Policy History & Recent Changes

Attachments and Related Documents