ModifiedColorado Rocky Mountain Health PlansPolicy N/A

Professional/Technical (PC/TC) reimbursement policy

Governs reimbursement methodology for CPT/HCPCS codes with professional and technical component considerations for UnitedHealthcare Community Plan Medicaid products; affects providers billing on CMS1500/UB04 across network and non-network physicians and qualified health care professionals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProfessional/Technical (PC/TC) reimbursement policy

Policy CodePolicy N/A

Change TypeAttachment and verbiage updatesclarifications and code list additions

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill drug administration codes 96360-96379, 96401-96425, and 96521-96523 for separate reimbursement when provided in POS 24.

SourceLink

POLICY UPDATE CHANGES

ASCFS Addendum BB PC/TC Indicator 3 Codes list will not be reimbursed as they represent Technical Component services only.

UnitedHealthcare will not reimburse drug administration codes 96360-96379, 96401-96425, and 96521-96523 when reported in POS 24 by physicians/QHPs.

Professional Component with an Evaluation and Management Service section wording and Radiological Codes Requiring Attached Report attachment were updated.

ASCFS Addendum BB PC/TC Indicator 1 Codes list and ASCFS Addendum BB PC/TC Indicator 3 Codes list updated.

Verbiage for Professional Component with an Evaluation and Management Service and Radiological Codes Requiring Attached Report updated.

ASCFS Addendum BB PC/TC Indicator 3 Codes were added/updated.

1–9PC/TC indicator categories referenced

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96360-96379 96401-96425 96521-96523

Drug admin codes not reimbursed in POS 24

TC not reimbursedASC POS 24 rule

QuarterlySplit update cadence

First-in, first-outDuplicate/repeat payment method

Coverage and Reimbursement Criteria

PC/TC reimbursement criteria

General reimbursement rules for PC/TC eligible codes.

Codes with CMS PC/TC Indicator 1 are eligible for split reimbursement into a Professional Component (PC) reported with modifier 26 and a Technical Component (TC) reported with modifier TC, and are reimbursed at a percentage of the Global Service Allowable Amount unless a provider contract specifies otherwise.

CPT/HCPCS codes assigned CMS PC/TC Indicators 0, 2, 3, 4, 5, 7, 8, and 9 are not eligible to be submitted with modifiers 26 and/or TC; codes with Indicator 6 are not eligible for reimbursement when submitted with modifier TC.

For services furnished in a facility (POS 19, 21, 22, 23, 26, 34, 51, 52, 55, 56, 57 or 61), the facility is reimbursed for the Technical Component and UnitedHealthcare will reimburse only the Professional Component when applicable and when proper modifiers/indicators are present.

When a physician or other qualified Health Care Professional provides equipment to perform the service in a facility POS, only the facility may be reimbursed for the Technical Component.

Professional/Technical Component codes with CMS PC/TC Indicators 2, 3, 4, 5, 6, or 8 that are eligible for reimbursement are reimbursed at 100% of the Allowable Amount when applicable.

Gap fill codes that are eligible for PC/TC but without RVU data are allowed at 100% of the Allowable Amount for both PC and TC when no RVU data exists.

Reimbursement criteria and exclusions

Coverage and reimbursement rules, including exclusions and required documentation, as specified below:

Drug administration codes CPT 96360-96379, 96401-96425, and 96521-96523 are considered included in the facility payment when reported in POS 24 and will not be reimbursed to physicians or other qualified Health Care Professionals when reported in POS 24.

Codes listed as PC/TC Indicator 3 in ASCFS Addendum BB represent Technical Component only and will not be reimbursed in POS 24.

For duplicate or repeat identical CPT/HCPCS codes reported for the same patient on the same date of service, UnitedHealthcare follows a first-in, first-out claim payment methodology and will reimburse only one physician/QHP for that service unless separate consideration is supported by appropriate modifiers.

Separate reimbursement considered when any of the following modifiers are appended

Modifier 26 or TC appended to indicate PC or TC as applicable for consideration when multiple submissions exist for Global Service (PC/TC Indicator 1).

PC/TC reimbursement criteria

Coverage and reimbursement are contingent on PC/TC indicator, place of service, modifiers, and required documentation.

Services with PC/TC Indicator 3 (Technical Component only) or Indicator 9 (PC/TC concept not applicable) are not reimbursable when submitted with the Professional Component modifier 26.

When PC/TC Indicator 1 codes are reported in CMS POS 24 (ambulatory surgical center), only the Professional Component (modifier 26) will be reimbursed; certain PC/TC Indicator 3 codes reported in POS 24 will be denied as specified in ASCFS Addendum BB.

Radiological PC/TC Indicator 1 codes reported globally or with modifier 26 and billed with an E/M service require an attached written radiology interpretation report; absence of the report may result in denial of separate reimbursement.

Code Classifications, Lists, and Billing Rules

PC/TC indicator classificationsmixed

0	Description = Physician Service Codes.
1	Description = Diagnostic Tests.
2	Description = Professional Component Only Codes.
3	Description = Technical Component Only Codes.
4	Description = Global Test Only Codes.
5	Description = Incident To Codes.
6	Description = Laboratory Physician Interpretation Codes.
7	Description = Physical therapy service, for which payment may not be made.
8	Description = Physician interpretation codes.
9	Description = Not Applicable

Drug administration codes excluded in POS 24CPTNot Covered

96360-96379, 96401-96425, 96521-96523

Drug administration codes considered included in the facility payment when reported in POS 24 and not reimbursed to physicians/QHPs.

PC/TC attachment code listsmixedCovered

ASCFS Addendum BB PC/TC Indicator 1 codes	List of PC/TC Indicator 1 codes with percentage splits; attachments specify codes requiring attached report and gap-fill codes.
ASCFS Addendum BB PC/TC Indicator 3 codes	List of PC/TC Indicator 3 codes that represent Technical Component only and will not be reimbursed in POS 24.

Drug administration codes excluded in POS 24CPTNot Covered

96360-96379, 96401-96425, 96521-96523

Drug administration codes considered included in the facility payment when reported in POS 24 and not separately reimbursed to physicians/QHPs.

Referenced PC/TC code listsmixed

CS-Laboratory-Codes-with-a-PCTC-Indicator-3-or-9	A list of codes that have been assigned a PC/TC Indicator of 3 or 9.
CS-ASCFS-Addendum-BB-PCTC-Indicator-1-Codes	A list of codes with a PC/TC Indicator 1 that when reported in CMS POS 24 only the Professional Component (modifier 26) will be reimbursed.
ASCFS Addendum BB PC/TC Indicator 3 Codes	A list of codes with a PC/TC Indicator 3 that when reported in CMS POS 24 will be denied.
Radiological Codes Requiring Attached Report	A list of PC/TC Indicator 1 radiology codes reported globally or appended with modifier 26 requiring a written interpretation radiology report when billed with an E/M service.

inv-09: Split tolerance

Split toleranceUnitedHealthcare splits differ no more than 2.5% from CMS Non‑Facility Total RBRVS per CPT/HCPCS code; splits are updated quarterly.

Source of splitsPercentage splits developed from CMS Non‑Facility Total RBRVS (NPFS) and attached to the policy.

Gap fill handlingGap Fill Codes without RVUs are allowed at 100% of the Allowable Amount for both PC and TC when no RVU data exists.

Quarterly updatesProfessional/Technical splits are updated quarterly to align with current RBRVS data.

Tolerance justificationSplits differ no more than 2.5% (for each CPT and HCPCS code) from CMS Non‑Facility Total RBRVS based percentage splits.

Provider Billing Responsibilities and Required Actions

Billing Rule

Claims Submission Responsibility and Application

You are responsible for submission of accurate claims using CPT, CMS and other coding guidelines. This policy applies to UnitedHealthcare Community Plan Medicaid product and to services billed on the CMS-1500 (or electronic equivalent). Claims must accurately reflect the codes that describe the services rendered; other factors (benefit design, contracts, state/federal rules, other policies) may affect reimbursement.

Denial Risk

Duplicate/Repeat Services and Modifier Requirements

UnitedHealthcare Community Plan follows a "first in, first out" claim payment methodology for duplicate or repeat services. When duplicate or repeat services are received, payment consideration will be given only to the first claim unless subsequent claims include the appropriate modifier demonstrating a distinct service. For the Same Individual physician or QHP reporting global (PC/TC Indicator 1) or stand-alone (PC/TC Indicator 2, 3, or 4) services more than once on separate lines, only services reported with appropriate modifiers will be considered for separate reimbursement. When the same PC/TC Indicator 6 or 8 service is reported more than once, separate consideration is limited to claims with modifier 59, XE, XP, XS, XU or 91. When the same global service is reported by different providers on the same date, only the second claim with an appropriate modifier will be considered for separate reimbursement. PC/TC 4 services billed with PC/TC 2 or 3 on the same date for the same member will be denied unless billed with an appropriate modifier.

Key Definitions

inv-19: Same individual rendering services reporting the same Federal Tax Identification number

DefinitionSame Individual Physician or Other Qualified Health Care Professional (QHP) = the same individual rendering health care services reporting the same Federal Tax Identification number.

RelevanceUsed to determine when duplicate/repeat rules and PC/TC component submission (PC, TC, global) apply to the same provider.

ImplicationIf the same individual reports both PC and TC for a service, UnitedHealthcare may consider both services eligible unless otherwise restricted by the policy.

inv-20: PC and TC modifier definitions

Professional Component (PC) modifierPC is reported with modifier 26 (supervision and interpretation).

Technical Component (TC) modifier

Policy Revision History

2026-04-26attachment_updateLatest

ASCFS Addendum BB PC/TC Indicator 1 and Indicator 3 code lists updated; history entries prior to 4/26/2024 were archived.

2026-04-01verbiage_update

Policy section 'Professional Component with an Evaluation and Management Service' and the 'Radiological Codes Requiring Attached Report' attachment verbiage were updated.

2026-02-15attachment_addition_update

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProfessional/Technical (PC/TC) reimbursement policy

Policy CodePolicy N/A

Change TypeAttachment and verbiage updatesclarifications and code list additions

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill drug administration codes 96360-96379, 96401-96425, and 96521-96523 for separate reimbursement when provided in POS 24.

SourceLink

On This Page

Modifiers 59, XE, XP, XS, XU, or 91 appended for duplicate reporting of PC/TC Indicator 6 or 8 services to allow separate consideration.

When a PC/TC Indicator 1 radiology code (reported globally or with modifier 26) is billed the same day as an E/M service by the same physician/QHP, a distinctly identifiable signed written radiology interpretation report must be submitted for separate reimbursement; modifier 25 on the E/M does not remove this requirement.

Attachments and referenced lists (Radiological Codes Requiring Attached Report; CS-Laboratory-Codes-with-a-PCTC-Indicator-3-or-9; CS-Gap-Fill-Codes; CS-ASCFS-Addendum-BB lists) provide the specific codes referenced by the rules above and must be consulted for claim adjudication details.

If a global service is paid first, subsequent component claims may be denied; if a component is paid first, subsequent global claims may be denied or paid only for the remaining component per policy examples.

inv-10: Duplicate/repeat per day

Per‑day duplicate ruleOnly one reimbursement is allowed for identical CPT/HCPCS codes submitted for the same patient on the same date of service, regardless of Maximum Frequency per Day (MFD).

DefinitionDuplicate or Repeat Services are identical CPT/HCPCS codes assigned PC/TC Indicator 1,2,3,4,6 or 8 submitted on separate claim lines or different claims for the same patient/date.

First‑in, first‑outUnitedHealthcare follows a first‑in, first‑out claim payment methodology and will reimburse only one physician/QHP for duplicate/repeat services.

Modifiers may allow separate reimbursementSeparate consideration may be given when appropriate modifiers are appended (e.g., 26, TC, 59, XE, XP, XS, XU, 91, 76, 77) as applicable.

inv-11: PC/TC Indicator 3 or 9 override

PC/TC Indicator 3 or 9 overrideServices assigned PC/TC Indicator 3 (technical component only) or Indicator 9 (PC/TC concept not applicable) are not reimbursable when submitted with the Professional Component modifier 26.

Attachments referencedCS-Laboratory-Codes-with-a-PCTC-Indicator-3-or-9 and ASCFS Addendum BB PC/TC Indicator 3 Codes identify affected codes.

EffectClaims submitted with modifier 26 on codes in these indicator groups will be denied per policy.

First-in, first-out claim payment methodology applies for duplicate/repeat services.
Global service (PC/TC Indicator 1) reported multiple times: only lines with appropriate modifiers considered for separate reimbursement.
Same PC/TC Indicator 6 or 8 reported multiple times: modifiers 59, XE, XP, XS, XU or 91 required for separate consideration.
Different providers reporting same global service on same date: second claim must include appropriate modifier for separate reimbursement.
PC/TC 4 billed with PC/TC 2 or 3 for same member/date: deny unless appropriate modifier present.

Documentation Required

Radiology Professional Component with Same-day E/M

The professional component (modifier 26) for radiology services assigned PC/TC Indicator 1 is generally considered included in the Evaluation and Management (E/M) service when the same physician or QHP performs both services on the same date. To be considered for additional reimbursement when billing the professional component (modifier 26) or when the radiology code is reported globally on the same day as an E/M, the provider must submit a distinctly identifiable signed written radiology interpretation report separate from the E/M documentation. Radiology codes that describe fluoroscopic or ultrasonic guidance for placement of a needle, catheter, or tube are an exception. Submission of the written radiology report is required even when modifier 59, XE, XP, XS or XU is reported.

PC/TC Indicator 1 radiology interpretation is usually included in same-day E/M when performed by the same physician/QHP.
To be eligible for separate reimbursement for modifier 26 or a global radiology code on the same date as an E/M, submit a distinctly identifiable signed written radiology interpretation report.
Exception: radiologic guidance codes for placement of needles, catheters, or tubes (fluoroscopic/ultrasonic) are handled separately.
Written radiology report required even if modifier 59, XE, XP, XS or XU is appended.

TC is reported with modifier TC.

PC/TC Indicator 1 contextCodes with PC/TC Indicator 1 may be split into PC and TC and the appropriate modifiers must be used to report each component.

inv-21: Professional Component

DefinitionProfessional Component (PC) represents the physician or QHP work portion — supervision and interpretation that results in a written narrative report and directly contributes to diagnosis or treatment.

IdentificationIn appropriate circumstances, PC is identified by appending modifier 26 or by reporting a stand‑alone code that describes the PC only.

IncludesPhysician work, practice overhead, malpractice expense, supervision, interpretation, and written report.

inv-22: Technical Component

DefinitionTechnical Component (TC) is the performance portion (technician, equipment, facility) of the procedure.

IdentificationIn appropriate circumstances, TC is identified by appending modifier TC or by reporting a stand‑alone code that describes the TC only.

IncludesTechnician services, equipment usage, and facility resources required to perform the procedure.

inv-23: Duplicate or Repeat Services

DefinitionDuplicate or Repeat Services = identical CPT or HCPCS codes assigned PC/TC Indicator 1,2,3,4,6 or 8 submitted for the same patient on the same date of service on separate claim lines or different claims regardless of MFD.

Payment consequenceOnly one physician/QHP will be reimbursed for duplicate/repeat services; modifiers may affect consideration for separate payment.

Review processUnitedHealthcare will review modifier usage (26/TC and other distinct modifier codes) to determine eligibility for separate reimbursement.

inv-24: Global Service

DefinitionGlobal Service includes both a Professional Component and a Technical Component (PC + TC).

IdentificationA Global Service is identified by reporting the PC/TC split eligible procedure code with no modifier attached or by reporting a stand‑alone global code.

AssertionSubmission of a Global Service asserts the same individual provided supervision/interpretation (PC) and the technician/equipment/facility (TC).

inv-25: PC/TC Indicator 3

Indicator 3 definitionPC/TC Indicator 3 = Technical Component only code; these services are not reimbursable when submitted with modifier 26.

ASCFS Addendum BBCodes listed in ASCFS Addendum BB as Indicator 3 represent TC‑only services and will not be reimbursed in ASC (POS 24) when billed to physicians.

Policy effectClaims with modifier 26 appended to Indicator 3 codes will be denied per policy guidance.

inv-26: PC/TC Indicator 9

Indicator 9 definitionPC/TC Indicator 9 = PC/TC concept does not apply; these services are not reimbursable when submitted with modifier 26.

EffectSubmission of modifier 26 on Indicator 9 codes will result in denial under this policy.

AttachmentCS-Laboratory-Codes-with-a-PCTC-Indicator-3-or-9 lists codes assigned Indicator 9 for reference.

inv-27: PC/TC Indicator 1

Indicator 1 ASC ruleWhen PC/TC Indicator 1 codes are reported in CMS POS 24 (ambulatory surgical center), only the Professional Component (modifier 26, PC) will be reimbursed.

Radiology report requirementRadiological Indicator 1 codes reported globally or with modifier 26 and billed with an E/M require an attached written radiology interpretation report for separate reimbursement.

AttachmentsCS-ASCFS-Addendum-BB-PCTC-Indicator-1-Codes lists the Indicator 1 codes and related guidance for ASC POS 24.

ASCFS Addendum BB PC/TC Indicator 1 codes updated and ASCFS Addendum BB PC/TC Indicator 3 codes added/updated.

2025-11-23attachment_update

Policy list update: ASCFS Addendum BB PC/TC Indicator 3 codes updated.