CurrentPremera BluecrossPolicy N/A

Modifiers 26 (professional) and TC (technical) billing and reimbursement

Defines when Premera recognizes and reimburses separately billed professional (modifier 26) and technical (modifier TC) components of services, and who it applies to across Premera and affiliated lines of business for professional claims submitted on CMS-1500 or 837P forms.

Policy Summary

PayerPremera Bluecross

PolicyModifiers 26 (professional) and TC (technical) billing and reimbursement

Policy CodePolicy N/A

Change TypeIncorporated Modifier TC contentclarified coding indicator use (PCITC flags 1 and 6)

Effective DateN/A

Next Review DateN/A

Key ActionAppend modifier 26 for professional component claims and modifier TC for technical component claims, per NPFS PCITC indicators.

SourceLink

POLICY UPDATE CHANGES

Modifier TC (technical component) recognition and reimbursement details were incorporated into this policy.

Clarified that the purpose pertains to professional services billed on CMS-1500 or 837P claim forms and added PCITC Indicator flags 1 and 6 to Codes/Coding Guidelines.

PCITC 1 & 6NPFS indicator flags the plan recognizes for modifier use

5 entitiesLines of business in scope

TC onlyMultiple imaging reductions apply to

annualReview history

Modifier-Based Coverage Rules

Modifier-based coverage criteria

Reimbursement is allowed only when modifier use and code PCITC indicators meet the Plan's requirements. Covered when ALL of the following are met:

The Plan uses the current CMS NPFS (PCITC) indicator to determine whether a CPT/HCPCS code has a professional/technical split and is eligible for separate reimbursement.

ALL of the following

PCITC indicator
- PCITC indicator 1: codes with both professional and technical components — may be billed with modifier 26 for the professional component and modifier TC for the technical component as appropriate.
- PCITC indicator 6: laboratory physician interpretation codes — may be billed with modifier 26; modifier TC is not permitted.

Policy Summary

PayerPremera Bluecross

PolicyModifiers 26 (professional) and TC (technical) billing and reimbursement

Policy CodePolicy N/A

Change TypeIncorporated Modifier TC contentclarified coding indicator use (PCITC flags 1 and 6)

Effective DateN/A

Next Review DateN/A

Key ActionAppend modifier 26 for professional component claims and modifier TC for technical component claims, per NPFS PCITC indicators.

SourceLink

On This Page

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NPFS Indicators and Coding Guidance

NPFS PCITC indicatorsmixedCovered

PCITC indicator 1	Diagnostic tests for Radiology Services: codes that describe diagnostic tests and have BOTH a professional and technical component — may be billed with modifier 26 (professional) and modifier TC (technical) as appropriate.
PCITC indicator 6	Laboratory Physician Interpretation Codes: clinical laboratory codes for which a separate payment for interpretations by laboratory physicians may be made; may be billed with modifier 26 for the professional component; modifier TC cannot be used.

NPFS PCITC reliance — modifier appropriateness

Policy reliancePlan uses the CMS NPFS Relative Value file PCITC indicator to determine whether a CPT/HCPCS code has a professional/technical split and is eligible for modifier 26 or TC reimbursement.

Recognized PCITC indicatorsPCITC indicator 1 (both professional and technical components) and PCITC indicator 6 (laboratory physician interpretation codes) are the flags the Plan recognizes for modifier use.

Ineligible codesCPT/HCPCS codes not identified in the NPFS as having a professional/technical split are not eligible for reimbursement when billed with modifier 26 or modifier TC.

Modifier applicationCodes with PCITC indicator 1 may be billed with modifier 26 for the professional component and modifier TC for the technical component as appropriate; PCITC indicator 6 codes may be billed with modifier 26 only (TC not permitted).

Billing Rules and Provider Instructions

Billing Rule

Billing rules for professional (26) and technical (TC) components

Append modifier 26 when billing only the professional component; append modifier TC when billing only the technical component. Do not append modifier 26 or TC to codes that NPFS PCITC indicators mark as inappropriate (stand-alone, global, physician-only, E&M, incident-to, concept-not-applicable, etc.). Reimbursement will be adjusted to reflect only the professional (26) or technical (TC) component; procedure code/modifier combinations that are not appropriate will be denied.

Plan uses the CMS NPFS PCITC indicators to determine which codes may be billed with modifier 26 or TC (PCITC indicators 1 and 6 recognized for 26; indicator 1 recognized for TC).
CPT/HCPCS codes not identified in NPFS as having a professional/technical split are ineligible for 26/TC reimbursement.
Modifier 26 and TC are not appropriate on E&M, stand-alone, physician-service-only, incident-to, or codes where the PCITC concept does not apply; such claims will be denied.

Billing Rule

Multiple imaging reductions apply to TC only

When multiple diagnostic radiology imaging services are performed in the same session by the same provider on the same patient, multiple procedure reductions are applied to the technical component (TC) only.

Reductions apply only to the technical component billed with modifier TC when multiple applicable imaging services occur in the same session by the same physician or qualified healthcare professional.

Key Terms

Professional Component

DefinitionProfessional Component: supervision, interpretation, and written report of a procedure provided by a physician or other qualified healthcare professional; reported by appending modifier 26 to the CPT/HCPCS code.

Typical servicesIncludes physician interpretation and the generation of the written report even if the physician did not perform the test personally.

Billing guidanceAppend modifier 26 when billing only the professional component on CMS-1500 or 837P claim forms for applicable codes identified by NPFS PCITC indicators.

Technical Component

DefinitionTechnical Component: services of the technician, related equipment, supplies, and institutional charges required to perform the procedure; reported by appending modifier TC to the CPT/HCPCS code.

Typical servicesIncludes equipment, supplies, clinical staff such as technicians, and facility-related charges associated with performing the procedure.

Multiple procedure reductionsMultiple diagnostic radiology procedure reductions are applied to the technical component (TC) only when multiple imaging services are performed in the same session by the same provider.

Billing guidanceAppend modifier TC when billing only the technical component on CMS-1500 or 837P claim forms for applicable codes identified by NPFS PCITC indicator 1.

Global Service and Stand-Alone Procedure Code

Global serviceGlobal Service: both professional and technical components are rendered by the same provider; modifiers 26 and TC are NOT appended to a global service code.

Stand-alone procedure codesStand-alone codes describe only the professional component, only the technical component, or only the global test; modifier 26 and TC cannot be billed with these codes.

ApplicabilityModifiers 26 and TC are inappropriate for codes defined by code description as physician-service-only, E&M, incident-to, or other codes where PCITC/PC concept does not apply.