Professional Component: Modifier -26
Governs reimbursement handling for the professional component of procedures (modifier -26) and how claims are edited and paid when professional and technical components are split; applies to all product types and providers submitting professional claims in specified places of service.
No material clinical or coverage changes in this revision.
When Professional Component (Modifier -26) Applies
Professional claim processing and place of service
Rules for how professional claims are evaluated when billed in institutional settings and where this policy applies.
Professional claim processing and applicability
- Applies to professional claims billed in the following Places of Service: 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56, 61.
- Policy applies to the current claim only (does not retroactively adjust prior claims).
- When a professional claim is submitted without modifier -26 in an institutional setting, the plan's code editing software denies the original service line and automatically adds a new service line with modifier -26 appended to the procedure code.
- The added service line with modifier -26 is recommended for payment; the original provider-submitted line remains on the claim (no change to how the provider originally billed).
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