CurrentEmpire BluecrossPolicy C-20004

Modifiers 26 and TC (Professional and Technical Component) reimbursement

Governs Anthem (Empire BlueCross) reimbursement rules for billing professional (Modifier 26) and technical (Modifier TC) components of services for commercial members, including when each component or the global procedure is reimbursed and facility billing restrictions.

Policy Summary

PayerEmpire Bluecross

PolicyModifiers 26 and TC (Professional and Technical Component) reimbursement

Policy CodePolicy C-20004

Change TypeStand-alone code statement addedRelated Coding and Definitions updated

Effective DateOct 30, 2023

Next Review Date

Key ActionHealth Plan may request additional documentation for claims submitted with Modifier 26 or TC and may recoup payments if documentation is not provided.

SourceLink

POLICY UPDATE CHANGES

Added stand-alone code statement under Nonreimbursable section.

Updated Related Coding section comments and Definitions descriptions for modifiers 26 and TC.

1stand-alone code statement added (05/22/2024)

Severalrestrictive place of service codes

Allowedpost-payment review allowed

Portable X-rayportable X-ray suppliers billed TC

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Reimbursement Criteria for Modifiers 26 and TC

Reimbursement criteria for Modifiers 26 and TC

Rules governing reimbursement of professional (Modifier 26), technical (Modifier TC), and global procedure codes.

Reimbursement follows these component-specific and global rules:

ALL of the following

Professional component: When a physician or other qualified health care professional performs only the professional component of a global procedure or service, reimbursement is allowed when Modifier 26 is appended to the applicable procedure code.
Technical component: When the technical component is performed and billed separately, reimbursement is denoted by adding Modifier TC to the applicable procedure code.
Services or procedures billed by a physician or other qualified health care professional that are performed in facilities defined in the Related Coding section will not be reimbursed to the physician for the global procedure or the technical component; only the facility may be reimbursed for the technical component.

ALL of the following

Global procedure: If no Modifier 26 or TC is present and the same provider performed both the professional and technical components, the global procedure is reimbursed.
Duplicate service adjudication: When one provider reports a global procedure and a different provider reports the same procedure with Modifier 26 or TC for the same patient on the same date of service, the first charge approved by the Health Plan is eligible for reimbursement; subsequent charges are considered duplicates and are not separately reimbursed.

Nonreimbursable uses (any of the following):

Modifier 26 or Modifier TC reported on an Evaluation and Management (E/M) code is not allowed.
Modifier 26 or TC should not be used when a separate stand-alone code already describes the professional component only, technical component only, or the global test only for the selected diagnostic test.

ALL of the following

Documentation and recoupment: The Health Plan may perform post-payment review of claims submitted with Modifier 26 or Modifier TC and request additional documentation. If required documentation is not provided following the request, the Health Plan may recoup or recover monies previously paid on the claim.
Subject to contractual obligations.
Portable X-ray suppliers should bill only for the technical component by appending Modifier TC.

Place of Service Codes and Coding Rules

Place of Service codes restricting physician reimbursement for global/TCmixed

19	Off Campus-Outpatient Hospital - facility defined where physician will not be reimbursed for global/technical component
21	Inpatient Hospital - facility defined where physician will not be reimbursed for global/technical component
22	On Campus-Outpatient Hospital - facility defined where physician will not be reimbursed for global/technical component
23	Emergency Room Hospital - facility defined where physician will not be reimbursed for global/technical component
24	Ambulatory Surgical Center - facility defined where physician will not be reimbursed for global/technical component
51	Inpatient Psychiatric Facility - facility defined where physician will not be reimbursed for global/technical component
61	Comprehensive Inpatient Rehabilitation Facility - facility defined where physician will not be reimbursed for global/technical component

Provider Documentation and Duplicate Service Handling

Documentation Required

Post-payment documentation request

The Health Plan may perform post-payment review of claims billed with Modifier 26 or Modifier TC and request additional documentation; if requested documentation is not provided, the Health Plan may recoup or recover monies previously paid on the claim.

Requests are subject to contractual obligations.
Failure to provide documentation after request/notification may result in payment recoupment or recovery.

Billing Rule

Duplicate service adjudication

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

Definitions and Modifier Descriptions

Global Procedure (Definition)

DefinitionRepresents both the professional and technical component as a complete procedure or service identified by reporting the eligible procedure without Modifier 26 or TC.

BillingReport the procedure code without Modifier 26 or TC when the same provider performs both components.

Related ruleIf one provider reports the global procedure and another reports a component for the same date of service, only the first approved charge is reimbursed; subsequent charges are duplicates and not separately reimbursed.

Professional Component (Modifier 26)

DefinitionPortion of a charge representing the physician's (or other practitioner's) work in providing the service, including interpretation and report of the procedure.

How to report