CurrentUnitedHealthcarePolicy N/A

Professional/Technical (PC/TC) reimbursement policy

Defines UnitedHealthcare Community Plan's reimbursement methodology for CPT/HCPCS codes with professional and technical component indicators, including how splits, place of service, and specific code classes are reimbursed for Medicaid product claims submitted on CMS-1500/UB04 forms.

Policy Summary

PayerUnitedHealthcare

PolicyProfessional/Technical (PC/TC) reimbursement policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using CPT, CMS or other coding guidelines on CMS1500 or UB04 as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PC/TC 1–9CMS PC/TC indicator categories referenced

12 POSFacility POS treated as facility

Optum RBRVSGap-fill method

Indicator 3Not reimbursed in ASC POS 24

96360–96523Drug admin exclusion POS 24

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Duplicate service rule

Coverage and Reimbursement Criteria

PC/TC reimbursement criteria

Reimbursement determination for PC/TC-eligible services.

UnitedHealthcare uses CMS PC/TC indicators (NPFS) to determine whether a CPT or HCPCS procedure code is eligible for separate Professional Component (PC) and Technical Component (TC) reimbursement; codes assigned PC/TC Indicator 1 may be split into PC (modifier 26) and TC (modifier TC).

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

When eligible, Professional and Technical Component reimbursement for PC/TC Indicator 1 services is calculated as a percentage of the Global Service Allowable Amount unless a provider contract specifies otherwise; when a contract applies, payments follow the contract’s fee schedule or percentage-of-charge provisions.

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

For services furnished in a facility (POS 19, 21, 22, 23, 26, 34, 51, 52, 55, 56, 57 or 61), UnitedHealthcare will reimburse only the Professional Component to the interpreting physician or QHP; the facility is reimbursed for the Technical Component. To be considered for Professional Component reimbursement in a facility POS the service must meet the applicable CMS PC/TC indicator and modifier reporting requirements (e.g., Indicator 1 reported with modifier 26; Indicator 2 reported without 26/TC; Indicator 6 reported with 26; Indicator 8 reported without 26).

When a physician or QHP provides equipment to perform the service in a facility POS, only the facility may be reimbursed for the Technical Component; the policy treats the Technical Component as services reported with modifier TC or codes assigned Indicator 3.

Gap-Fill Codes: when CMS does not develop RVUs, UnitedHealthcare uses carrier/Optum/UnitedHealthcare-assigned RVUs (gap-fill process); PC/TC Indicator 1 diagnostic test codes without RVU splits may be allowed at 100% for both PC and TC as specified in attachments.

ASC (POS 24) handling: services listed in ASCFS Addendum BB with PC/TC Indicator 3 are technical-component-only codes and will not be reimbursed; certain Indicator 1 codes in ASCFS Addendum BB may be reimbursed only for the Professional Component in POS 24; drug administration codes identified by NCCI are included in facility payment (see separate criteria).

Exception for reproductive medicine laboratory procedures (CPT 89250-89398): special referral/reimbursement considerations may apply when facility labs cannot perform specialized services; if both facility and reference lab report the same service same day for same member, only the facility lab is reimbursed.

PC/TC and Duplicate Service Coverage Criteria

UnitedHealthcare Community Plan coverage stance for PC/TC component billing, duplicate services, modifier usage, and documentation requirements.

Codes listed in the ASCFS Addendum BB PC/TC Indicator 3 list will not be reimbursed when reported in CMS POS 24 (ambulatory surgical center) because they represent Technical Component only services.

Drug administration CPT codes 96360-96379, 96401-96425, and 96521-96523 reported by a physician or QHP in POS 24 are considered included in the facility payment and will not be reimbursed to the physician/QHP.

Duplicate/Repeat Services: when identical CPT/HCPCS codes assigned PC/TC Indicator 1, 2, 3, 4, 6 or 8 are reported for the same patient on the same date (same or different providers), only one physician/QHP will be reimbursed; UnitedHealthcare uses first-in, first-out claim payment methodology to determine which claim is paid.

Modifiers and separate consideration: UnitedHealthcare will give separate consideration for additional reimbursement only when appropriate modifiers are appended (examples include 26, TC, 59, XE, XP, XS, XU, 91, 76, 77). Absent appropriate modifiers, second and subsequent identical submissions will not be separately reimbursed.

PC/TC reimbursement and documentation criteria

Coverage and reimbursement rules related to PC/TC coding and radiology interpretation documentation.

Radiology interpretations reported globally or with modifier 26 that are billed on the same day as an E/M service require submission of a distinctly identifiable signed written radiology report separate from the E/M service before separate reimbursement for the radiology interpretation will be considered.

Modifier 25 on an E/M service does not eliminate the requirement to submit supporting documentation for a radiology interpretation billed with modifier 26; the radiology interpretation still requires documentation for separate reimbursement.

Laboratory codes assigned PC/TC Indicator 3 (technical component only) or PC/TC Indicator 9 (PC/TC concept does not apply) are not reimbursable when submitted with modifier 26 (professional component), as the PC/TC concept does not apply or the codes are technical-only.

In CMS POS 24 (ASC), certain PC/TC Indicator 1 codes will have only the Professional Component reimbursed and certain Indicator 3 codes may be denied as specified in the ASCFS addenda; consult the ASCFS attachments for code-level determinations.

Code Lists, Modifiers, and Coding Rules

PC/TC Indicator Codesmixed

PC/TC Indicator 1	Global service eligible to be split into Professional Component (modifier 26) and Technical Component (modifier TC)
PC/TC Indicator 2	Professional Component Only codes
PC/TC Indicator 3	Technical Component Only codes
PC/TC Indicator 4	Global Test Only codes (stand-alone)
PC/TC Indicator 5	Incident To codes (not allowed in facility POS)
PC/TC Indicator 6	Laboratory Physician Interpretation codes
PC/TC Indicator 8	Physician interpretation codes
PC/TC Indicator 9	Not Applicable / PC/TC concept not applicable

ASCFS Addendum BB PC/TC Indicator 3 CodesCPTNot Covered

ASCFS Addendum BB PC/TC Indicator 3 list

Codes representing Technical Component only that will not be reimbursed when reported in CMS POS 24 (ASC).

Drug administration codesCPTNot Covered

96360-96379, 96401-96425, 96521-96523

Drug administration codes considered included in facility payment when reported in POS 24; not reimbursed when billed by physician/QHP in POS 24.

PC/TC and related code listsmixedCovered

Professional/Technical Component Codes (PC/TC Indicator 1)	Codes that have both a Professional Component and a Technical Component; modifiers 26 and TC may be used.
Codes Subject to the PC/TC Concept Without RVU Splits	PC/TC Indicator 1 diagnostic test codes subject to the PC/TC component concept without RVU splits; allowed at 100% for both components.
Gap-Fill Codes	PC/TC Indicator 1 diagnostic test codes for which CMS does not develop RVUs or which CMS states may be carrier-based; assigned gap-fill RVUs or UnitedHealthcare-assigned RVUs.
Laboratory Codes with PC/TC Indicator 3 or 9	Lists of laboratory codes assigned indicator 3 (technical component only) or 9 (PC/TC concept not applicable); these services are not reimbursable when submitted with modifier 26.
ASCFS Addendum BB PC/TC Indicator 1 and 3 Codes	Attachment lists specifying ASCFS Addendum BB treatment: certain Indicator 1 codes reported in POS 24 only have the Professional Component reimbursed; Indicator 3 codes in POS 24 will be denied.
Radiological Codes Requiring Attached Report	PC/TC Indicator 1 radiology codes reported globally or with modifier 26 that require submission of a distinctly identifiable signed written radiology report when billed with an E/M service for separate reimbursement consideration.

inv-08: Split percent variance

Split percent varianceUnitedHealthcare splits differ no more than 2.5% from CMS Non-Facility Total RBRVS based percentage splits; splits are updated quarterly and current splits are attached to the policy.

Data source for splitsSplits developed nationally from the CMS Non-Facility Total RBRVS-based percentage splits (NPFS).

Gap-fill handling for missing RVUsWhen CMS does not develop RVUs, Optum The Essential RBRVS (first quarter update) is used for Gap Fill Codes; if no data, eligible Gap Fill Codes are allowed at 100% for both PC and TC.

inv-09: Duplicate/Repeat service rule

Duplicate/Repeat reimbursement ruleOnly one physician/QHP will be reimbursed when identical CPT/HCPCS codes (PC/TC indicators 1,2,3,4,6,8) are submitted for the same patient and date of service.

Provider Billing, Documentation, and Submission Requirements

Billing Rule

Duplicate/Repeat Services — general rule

This section applies when Duplicate or Repeat Services (identical CPT or HCPCS codes assigned a PC/TC Indicator 1, 2, 3, 4, 6, or 8) are reported for the same patient on the same date of service. When Duplicate or Repeat Services are reported, only one physician or other qualified health care professional (QHP) will be reimbursed for those services. UnitedHealthcare Community Plan follows a "first in, first out" claim payment methodology to determine which claim will be considered for reimbursement when duplicate or repeat claims are received.

Duplicate/Repeat Services = identical CPT/HCPCS with PC/TC Indicator 1,2,3,4,6,8 on same patient/date
Only one reimbursement allowed for Duplicate/Repeat Services regardless of Maximum Frequency per Day (MFD)
UnitedHealthcare follows first-in, first-out claim payment methodology

Key Terms and Definitions

inv-17: Same Individual Physician or QHP

Same Individual physician/QHPDefined as the same individual rendering health care services reporting the same Federal Tax Identification number.

ScopeApplies when determining duplicate/repeat submissions and when evaluating professional vs technical component submissions by the same practitioner.

Use in policy rulesReferenced in rules for reimbursement of global services, PC/TC component submissions, and duplicate/repeat services determinations.

inv-18: Professional Component (PC)

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

DefinitionPC is the physician/QHP work portion that results in a written narrative report included in the patient record and directly contributes to diagnosis/treatment.

Policy Summary

PayerUnitedHealthcare

PolicyProfessional/Technical (PC/TC) reimbursement policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using CPT, CMS or other coding guidelines on CMS1500 or UB04 as specified.

SourceLink

On This Page

When an E/M and a PC/TC Indicator 1 radiology service are performed by the same individual on the same day, the radiology interpretation is considered included in the E/M unless a distinctly identifiable signed written radiology report is submitted; even when modifiers such as 59, XE, XP, XS or XU are reported, the written report is required for separate reimbursement consideration.

If a global service claim is adjudicated and allowed first, subsequent component claims may be denied; conversely, if a component claim is allowed first, subsequent global claims may only be reimbursed for the remaining component as appropriate.

state exceptions

State-specific exceptions apply for certain codes and places of service (examples listed for FL, KS, KY, MD, MS, NJ, NM, NY, OH, PA, TN, TX, VA, WA, WI). Refer to the state exceptions section for details.

Policy attachments provide detailed lists (e.g., Radiological Codes Requiring Attached Report; CS-Laboratory-Codes-with-a-PCTC-Indicator-3-or-9; ASCFS Addendum BB lists; Gap-Fill codes) which govern specific code handling referenced above.

Some PC/TC Indicator 1 diagnostic test codes without RVU splits are allowed at 100% for both components as listed in the policy attachments; other PC/TC Indicator 1 codes are gap-fill codes with carrier- or UnitedHealthcare-assigned RVUs per the attachments.

Attachments referenced by this policy include: lists of Professional/Technical Component Codes (PC/TC Indicator 1 diagnostic tests); Codes Subject to the PC/TC Concept Without RVU Splits; Gap-Fill Codes; Laboratory Codes with PC/TC Indicator 3 or 9; Radiological Codes Requiring Attached Report; ASCFS Addendum BB PC/TC Indicator 1 and 3 Codes; and state-specific exclusion lists.

Definition of Duplicate/Repeat ServicesIdentical 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.

Claim payment methodologyUnitedHealthcare follows a 'first in, first out' claim payment methodology to determine which duplicate/repeat claim is considered for reimbursement.

inv-10: ASC POS 24 handling

ASC (POS 24) PC/TC handlingFor CMS POS 24 (ambulatory surgical center), certain PC/TC Indicator 1 codes will have only the Professional Component (modifier 26) reimbursed; certain PC/TC Indicator 3 codes listed in ASCFS Addendum BB will be denied when reported in POS 24.

Technical component not reimbursed in ASCThe Technical Component reported with modifier TC or reported globally for ASCFS Addendum BB Indicator 1 codes will not be reimbursed when performed in POS 24.

Drug administration exclusion in POS 24Drug administration codes identified by CMS NCCI are considered included in facility payment and are not reimbursed to physicians/QHPs when reported in POS 24.

Documentation Required

Professional/Technical component handling

When services include separate Professional and Technical Components (PC/TC split), UnitedHealthcare Community Plan will review modifier 26 (professional component) and modifier TC (technical component) to identify Duplicate or Repeat Services. If the Same Individual physician or QHP reports both modifier 26 and modifier TC for the same PC/TC Indicator 1 service separately, both components will be considered eligible for reimbursement unless another portion of the policy applies.

If the same individual reports both modifier 26 and TC for the same PC/TC Indicator 1 service on the same date, both may be reimbursed if otherwise allowable
UnitedHealthcare will review modifier usage to determine duplicate/repeat status

Billing Rule

Modifier requirements and payment order

Separate consideration for duplicate or repeat submissions will only be given when the appropriate modifiers are appended as described below. Otherwise, the second and subsequent identical services will not be separately reimbursed. Applicable modifier guidance includes:

PC/TC Indicator 1 (global) or stand‑alone services (PC/TC 2,3,4): second and subsequent services are allowed only if an appropriate modifier is appended
When the same PC/TC 6 or 8 service is reported more than once, only reports with modifier 59, XE, XP, XS, XU or 91 will be considered for separate reimbursement
When the same global (PC/TC 1) service is reported by different providers on the same date, the second claim will be considered for reimbursement only if an appropriate modifier is appended
When one provider reports the global service and another reports modifier 26 or TC for the same service/date, separate reimbursement for the second claim requires an appropriate modifier
When a PC/TC 4 service is billed with a PC/TC 2 or 3 service for the same member/date by the same or different provider, the second and subsequent service will be denied unless billed with an appropriate modifier

When reimbursablePC (modifier 26) may be reimbursed separately for PC/TC Indicator 1 services where applicable and per place-of-service rules.

inv-19: Technical Component (TC)

Technical Component (TC) modifierTechnical Component is reported with modifier TC and represents the performance (technician/equipment/facility) of the procedure.

DefinitionTC is the technical portion (technician, equipment, facility) of the procedure and may be reimbursed separately for PC/TC Indicator 1 services unless restricted by POS or ASC rules.

Facility responsibilityWhen equipment is provided by a physician in a facility POS, only the facility may be reimbursed for the Technical Component.

inv-20: Facility place of service

Facility place of service listPOS considered facility: 19, 21, 22, 23, 26, 34, 51, 52, 55, 56, 57, 61.

Non-facility POSAll other POS not listed above are considered non-facility for the purposes of this policy.

Impact on PC/TC reimbursementIn a facility POS, UnitedHealthcare will typically reimburse only the Professional Component to interpreting physicians/QHPs; the facility is reimbursed for the Technical Component.

inv-21: Professional Component

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

ReportingIdentified by appending modifier 26 or by reporting a Stand-alone Code that describes the Professional Component only.

IncludesPhysician work, practice overhead, and malpractice expense associated with the professional services.

inv-22: Technical Component

Technical Component definitionThe Technical Component is the performance (technician/equipment/facility) portion of the procedure, identified by modifier TC or a Stand-alone Code describing the TC only.

IncludesTechnician services, equipment use, and facility resources needed to perform the procedure.

Reimbursement noteTC may not be reimbursed to physicians/QHPs in certain facility POS or ASC POS 24 per policy and ASCFS addenda.

inv-23: Global Service

Global Service definitionA Global Service includes both a Professional Component and a Technical Component; submission of a Global Service asserts the same individual provided both PC and TC.

ReportingIdentified by reporting the global procedure code with no PC/TC modifier or by reporting a Stand-alone Code for global test only services.

ImplicationIf a global service claim is allowed first, subsequent component claims may be denied per duplicate/repeat rules.

inv-24: Duplicate or Repeat Services

Duplicate or Repeat Services definitionIdentical 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.

Single reimbursementOnly one physician/QHP will be reimbursed for Duplicate or Repeat Services unless appropriate modifiers are appended and justify separate payment.

Modifier reviewUnitedHealthcare will review modifier 26 and TC (and other listed modifiers) when both components are reported separately to determine eligibility for reimbursement.

inv-25: PC/TC Indicator 1

PC/TC Indicator 1 descriptionCodes that have both a Professional Component and a Technical Component (PC/TC Indicator 1) and may be split into PC (modifier 26) and TC (modifier TC).

ListingIndicator 1 codes are listed in the CMS NPFS Relative Value Files with separate rows for global, TC and PC where applicable.

Reimbursement notesSome Indicator 1 codes may be subject to ASC POS 24 rules or be gap-fill codes handled per policy attachments.

inv-26: PC/TC Indicator 3

PC/TC Indicator 3 descriptionTechnical Component only codes (PC/TC Indicator 3).

Reimbursement in ASC (POS 24)Codes listed as Indicator 3 in ASCFS Addendum BB will not be reimbursed when reported in CMS POS 24 (ambulatory surgical center).

PC/TC policy impactServices with indicator 3 are not reimbursable when submitted with the Professional Component (modifier 26).

inv-27: PC/TC Indicator 9

PC/TC Indicator 9 descriptionThe concept of a PC/TC component does not apply to these codes (Indicator 9); PC/TC reporting and reimbursement rules do not apply.

Reimbursement implicationServices assigned indicator 9 should not be billed with modifier 26 or TC as PC/TC concept is not applicable.

Policy referenceIndicator 9 codes are listed in attachments (CS-Laboratory-Codes-with-a-PCTC-Indicator-3-or-9) and are not reimbursable when submitted with modifier 26.