CurrentmhnPolicy CC.PP.027

Professional Component: Modifier -26

Defines payment and claim-edit handling for the professional component (modifier -26) of services that have professional and technical components; applies to professional claims and specified places of service for members of Health Plan administered by Centene affiliates.

Policy Summary

Payermhn

PolicyProfessional Component: Modifier -26

Policy CodePolicy CC.PP.027

Change TypeNo material change

Effective Date01/01/2013

Next Review Date

Key ActionWhen billing the professional component separately, append modifier -26 to the procedure code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2013Effective date

10/13/2025Last review date

ALLApplies to

MultiplePlaces of service

Auto-add -26System behavior

Payment and Claim-Edit Rules

Payment and claim-edit rules

Application and reimbursement processing rules

Policy applies to the following: professional claims, and Place of Service 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56 and 61; current claim only.

When billing the professional component separately, providers should append modifier -26 to the usual procedure code.

If a professional claim is billed without modifier -26 in an institutional setting, the health plan's code editing software will deny the original service line and add a new payable service line with modifier -26 appended; the original line remains on the claim.

The added service line is recommended for payment and reflects the payable amount for the professional component (example: original line denied; added line with modifier -26 shows allow/pay values).

Modifiers and PC/TC Indicators

Policy Summary

Payermhn

PolicyProfessional Component: Modifier -26

Policy CodePolicy CC.PP.027

Change TypeNo material change

Effective Date01/01/2013

Next Review Date

Key ActionWhen billing the professional component separately, append modifier -26 to the procedure code.

SourceLink

On This Page

Modifiers for PC/TC splitModifierCovered

-26	Professional component modifier
TC	Technical component modifier

PC/TC indicator — overview (inv-03)

CMS PC/TC indicator 1Codes with a CMS PC/TC indicator of 1 are comprised of a Professional Component (PC) and a Technical Component (TC) and may be split into PC and TC (global service that may be split).

MPFSDB listingCodes assigned PC/TC indicator 1 are listed in the Medicare Physician Fee Schedule Database (MPFSDB) and the National Physician Fee Schedule Relative Value File (RVU).

Modifier mappingProfessional Component reported with modifier -26; Technical Component reported with modifier -TC.

Billing Actions and System Edits

Billing Rule

Provider billing action and system edit — append modifier -26 when billing professional component

The health plan evaluates professional claims billed from institutional settings for omission of the professional component modifier. If a procedure is billed without modifier -26 in an institutional Place of Service listed below, the claim-editing software will deny the original service line and create a replacement professional-component line by appending modifier -26 to the procedure code. The appended -26 line is recommended for payment. Providers should bill the professional component using modifier -26 when appropriate to ensure correct adjudication.

Affected places of service: 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56, 61
Applies to: Professional claims only
Operational behavior: If billed without modifier -26 in an institutional setting, the system will deny the original line and auto-add a professional component line with modifier -26
Payment recommendation: The auto-added -26 line is recommended for payment

Key Terms

Professional Component (PC) — definition (inv-05)

DefinitionThe professional component (PC) is physician work interpreting a diagnostic test or performing a procedure and includes indirect practice and malpractice expenses related to that work.

Modifier to useAppend modifier -26 to the usual procedure code when billing the professional component separately.

Context of useWhen a health care professional performs a procedure in an institutional setting that consists of both components, append only the professional component modifier (26) for physician services reported separately.

Technical Component (TC) — definition (inv-06)

DefinitionThe technical component (TC) is all non-physician work, and includes administrative, personnel and capital (equipment and facility) costs, and related malpractice expenses.

Modifier to useReport the technical component with modifier TC when billing the technical component separately.

Typical billing settingThe technical component is typically considered an institutional charge; in some cases the physician may own equipment and be responsible for associated expenses.

PC/TC indicator — MPFSDB meaning (inv-07)

Indicator meaningPC/TC indicator 1 in MPFSDB denotes codes comprised of professional and technical components (global service that may be split).

Components listingEach global service (indicator 1) is listed on a separate row in the MPFSDB followed immediately by separate rows for the corresponding Technical Component and Professional Component.

Use in claims processingCodes with this indicator may be billed as separate PC (-26) and TC (-TC) lines as appropriate per payer rules.