ModifiedUnitedHealthcarePolicy 2026R0012E

UnitedHealthcare CMS 1500 Reimbursement Policy — Professional/Technical (PC/TC) Components

Governs UnitedHealthcare reimbursement methodology for services billed on the CMS-1500 (and electronic equivalent), including determination and payment of professional and technical components (PC/TC) for CPT/HCPCS codes across UnitedHealthcare Commercial and Individual Exchange plans and applies to network and non-network physicians and QHPs.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Reimbursement Policy — PC/TC

Policy CodePolicy 2026R0012E

Change TypeMaterial revisions and code list updates

Effective Date

Next Review Date

Key ActionSubmit accurate claims on the CMS-1500 or electronic equivalent and include required documentation (e.g., signed radiology reports) to support separate PC reimbursement.

SourceLink

POLICY UPDATE CHANGES

Policy Section Update: Professional Component with an Evaluation and Management Service (noted 4/1/2026).

Policy List Updates: ASCFS Addendum BB PC/TC Indicator 1 and 3 codes updated on multiple dates including 3/29/2026 and 11/23/2025.

Questions and Answers additions including Q&A #6 and #7 added 10/1/2024.

2026R0012EIdentifier

Indicator 1Codes eligible for PC/TC split

POS 24ASC (POS 24) TC not reimbursed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

POS 19,21,22...Facility POS considered

PC/TC Coverage and Reimbursement Criteria

PC/TC reimbursement criteria

Reimbursement criteria by PC/TC indicator and place of service.

ALL of the following

ANY of the following
- CMS PC/TC Indicator 1 and reported with modifier 26
- CMS PC/TC Indicator 2 reported without modifier 26 or TC
- CMS PC/TC Indicator 6 and reported with modifier 26
- CMS PC/TC Indicator 8 reported without modifier 26

Services furnished in a Non-Facility POS (any POS other than the facility POS list): For codes assigned CMS PC/TC Indicator 1, UnitedHealthcare will consider reimbursement of both the Professional Component and the Technical Component when eligible.

Specific outpatient restriction for PC/TC Indicator 8 codes: Certain physician interpretation codes (PC/TC Indicator 8), e.g., CPT 85060, are subject to POS restrictions per policy and may not be reimbursed outside specified inpatient POS as noted in the coding guidance.

Gap‑fill allowance: PC/TC Indicator 1 diagnostic tests that lack established RVUs or for which CMS gap‑fill data apply may be allowed at 100% of the Allowable Amount for both Professional and Technical Components when no RVU splits exist.

Intraoperative neuromonitoring (IONM): When IONM services (95940 and G0453) and associated study codes are reported in a facility POS, the Technical Component will be denied.

Contract overrides: When a physician or QHP contract specifies professional and technical fees or percent‑of‑charge in the contract fee schedule, those contract terms govern instead of the standard percentage‑of‑global calculations.

Split calculation methodology: UnitedHealthcare calculates PC and TC reimbursement as a percentage of the Global Service Allowable Amount based on CMS/National RBRVS‑derived splits unless the contract specifies otherwise.

Reimbursement and billing criteria (excerpt)

UnitedHealthcare will apply the following criteria when adjudicating claims involving professional and technical components, place of service considerations, duplicate/repeat services, and related modifiers.

Non‑facility POS consideration: For services with CMS PC/TC Indicator 1 provided in a non‑facility POS, UnitedHealthcare will consider reimbursement for both Professional and Technical Components when eligible.

Mobile unit POS reporting and IONM: If a mobile unit serves an entity for which another POS exists, report that entity's POS; otherwise report POS 15. When intraoperative neuromonitoring (95940 and G0453) and associated study codes are reported in a facility POS, the Technical Component will be denied.

ASC/POS 24 (Ambulatory Surgical Center) rules: For services reported in POS 24 included in ASCFS Addendum BB, the Technical Component is not reimbursed on CMS‑1500; for ASCFS Addendum BB codes with PC/TC Indicator 1, only the Professional Component (modifier 26) will be reimbursed. Drug administration codes (CPT 96360-96379, 96401-96425, 96521-96523) reported by a physician or other QHP in POS 24 will not be reimbursed.

ASCFS Addendum BB PC/TC Indicator 3: Codes that represent Technical Component only in ASCFS Addendum BB will not be reimbursed as professional claims.

PC/TC coverage criteria

Reimbursement rules for PC/TC‑coded services and required documentation for separate payment.

Duplicate editing for PC/TC code series: If a global test and component codes exist in a code series, duplicate editing will deny the later‑submitted code: if the global test was received and allowed first, component code(s) will be denied; if a component code was received first, the global test will be denied. Modifiers 26 or TC are not used to change the intent when the intent is inherent in the code descriptions.

Radiology interpretation billed with E/M: When an E/M is billed on the same day as a radiology interpretation (modifier 26), a distinctly identifiable signed written radiology report must be submitted for separate reimbursement even if modifier 59, XE, XP, XS or XU is reported; modifier 25 on the E/M does not waive the documentation requirement for the radiology interpretation.

Repeat procedure modifiers: Use modifiers 76 or 77 to report repeat procedures performed at different episodes on the same day. Do not use 76/77 for repeat laboratory services; instead use 59, XE, XP, XS, XU or 91 as appropriate.

Facility technical component inclusion: Technical Component services performed in a facility setting are included in the facility global payment and are not separately reimbursable when reported by a physician or other QHP; a mobile unit may use POS 15 only if a facility claim has not been submitted for the same date.

Code Classifications, PC/TC Indicators, and Related Coding Rules

PC/TC indicator code classificationsmixed

PC/TC Indicator 1	Diagnostic tests comprised of professional and technical components; eligible for split (report PC with modifier 26 and TC with modifier TC)
PC/TC Indicator 2	Professional Component Only codes — reported without modifier 26 or TC
PC/TC Indicator 3	Technical Component Only codes — not eligible for modifier 26/TC split reimbursement
PC/TC Indicator 4	Global Test Only codes — not reimbursable to physician in facility POS
PC/TC Indicator 5	"Incident To" codes — not reimbursable in facility POS
PC/TC Indicator 6	Laboratory Physician Interpretation Codes — PC reported with modifier 26
PC/TC Indicator 8	Physician Interpretation Codes — typically reported without modifier 26; CPT 85060 example not reimbursed outside inpatient POS 21
PC/TC Indicator 9	Not Applicable — identifies services not eligible for PC/TC reimbursement

Drug administration and select procedure codes with TC/ASC rulesCPT | HCPCSNot Covered

96360-96379	Drug administration codes considered included in the facility payment; not reimbursed by physician/QHP in POS 24
96401-96425	Chemotherapy/antineoplastic drug administration series; included in facility payment; not reimbursed by physician/QHP in POS 24
96521-96523	Intravenous infusion/additional administration codes; included in facility payment; not reimbursed by physician/QHP in POS 24
95940, G0453	Intraoperative neuromonitoring services; TC denied when reported in a facility POS

ASCFS Addendum BB PC/TC indicatorsmixedNot Covered

PC/TC Indicator 1	For codes included in the ASCFS Addendum BB PC/TC Indicator 1 Codes list, only the Professional Component (PC, modifier 26) will be reimbursed; when reported globally or with modifier TC, the code will not be reimbursed.
PC/TC Indicator 3	Codes included in the ASCFS Addendum BB PC/TC Indicator 3 Codes list represent Technical Component services only and will not be reimbursed as professional claims.

PC/TC indicator code groupsmixedCovered

PC/TC Indicator 1	Codes with both Professional and Technical Components; modifiers 26 and TC can be used.
PC/TC Indicator 3	Technical Component Only codes; not reimbursable when submitted with modifier 26.
PC/TC Indicator 9	PC/TC concept does not apply; services not reimbursable when submitted with modifier 26.

ASCFS Addendum BB groupsmixedCovered

ASCFS Addendum BB PC/TC Indicator 1	When reported in CMS POS 24 (ASC), only the Professional Component (modifier 26) will be reimbursed.
ASCFS Addendum BB PC/TC Indicator 3	Codes in this list will not be reimbursed as they represent Technical Component services only in ASC context.

inv-09: Split variance tolerance

Variance toleranceUnitedHealthcare splits differ no more than 2.5% from CMS Non‑Facility Total RBRVS based percentage splits

Update frequencySplits updated quarterly

Basis for splitsDeveloped on a national level from CMS Non‑Facility Total RBRVS percentage splits (NPFS)

inv-10: Duplicate/Repeat Services per patient per date

Per‑patient/date reimbursementOnly one physician or QHP will be reimbursed when identical CPT/HCPCS codes with PC/TC indicators 1,2,3,4,6 or 8 are submitted for the same patient on the same date

Provider Responsibilities, Billing Instructions, and Documentation Requirements

Billing Rule

Claims submission responsibility

This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent (or successor). Providers must submit accurate claims on the CMS-1500 or electronic equivalent. This policy applies to all products and to all network and non‑network physicians and other qualified health care professionals (QHP), including non‑network authorized and percent‑of‑charge contract physicians and other QHPs.

Billing Rule

Duplicate or Repeat Services handling and modifier guidance

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, UnitedHealthcare will reimburse only one physician or other QHP. UnitedHealthcare follows a first‑in, first‑out claim payment methodology to determine which claim is considered for reimbursement. For services with both Professional and Technical Components reported separately, modifier 26 and TC will be reviewed to determine duplication. Separate consideration may be given when appropriate modifiers indicating distinct or repeat services are used; otherwise second and subsequent services will not be reimbursed.

Key Definitions and Modifier Glossary

inv-23: Same Individual Physician or QHP

DefinitionSame Individual Physician or QHP: the same individual rendering health care services reporting the same Federal Tax Identification number

Context of useUsed to determine when PC and TC are considered provided by the same practitioner for reimbursement and duplicate‑editing rules

Referenced in policy sectionsAppears in Overview and CMS 1500 definitions to establish identity for claims handling

inv-24: Professional Component (PC)

DefinitionProfessional Component (PC): the supervision and interpretation portion of a Global Service, reported with modifier 26

ComponentsRepresents physician work, practice overhead and malpractice expense and results in a written narrative report

ASC and Special Place-of-Service Coding Exceptions

Drug administration and select procedure codes with TC/ASC rulesCPT | HCPCSNot Covered

96360-96379	Drug administration codes considered included in the facility payment; not reimbursed by physician/QHP in POS 24
96401-96425	Chemotherapy/antineoplastic drug administration series; included in facility payment; not reimbursed by physician/QHP in POS 24
96521-96523	Intravenous infusion/additional administration codes; included in facility payment; not reimbursed by physician/QHP in POS 24
95940, G0453	Intraoperative neuromonitoring services; TC denied when reported in a facility POS

Billing Rule

ASC (POS 24) — ASCFS Addendum BB codes: TC not reimbursed; PC only for Indicator 1

When services are reported in POS 24 (Ambulatory Surgical Center) on a CMS-1500 claim, UnitedHealthcare will not reimburse the Technical Component for codes included in ASCFS Addendum BB; for PC/TC Indicator 1 codes in that list only the Professional Component (modifier 26) will be reimbursed.

ASCFS Addendum BB PC/TC Indicator 3 codes represent TC-only services and will not be reimbursed as professional claims.

Policy Updates and Change Log

2026-04-01Policy Section UpdateLatest

Updated Professional Component with an Evaluation and Management Service and revised the Attachment 'Radiological Codes Requiring Attached Report' description.

2026-03-29Policy List Update

Updated ASCFS Addendum BB PC/TC Indicator 1 codes list.

2026-02-15Policy List Update

Changed ASCFS Addendum BB PC/TC Indicator 3 codes from table to attached list and updated ASCFS Addendum BB PC/TC Indicator 1 codes; archived history entries prior to 2024-02-15.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Reimbursement Policy — PC/TC

Policy CodePolicy 2026R0012E

Change TypeMaterial revisions and code list updates

Effective Date

Next Review Date

Key ActionSubmit accurate claims on the CMS-1500 or electronic equivalent and include required documentation (e.g., signed radiology reports) to support separate PC reimbursement.

SourceLink

On This Page

Duplicate/Repeat Services: Identical CPT/HCPCS codes assigned PC/TC Indicator 1,2,3,4,6 or 8 submitted for the same patient on the same date of service — only one physician/QHP will be reimbursed. UnitedHealthcare reviews modifiers (26, TC, 59/XE/XP/XS/XU/91, 76/77) to determine separate reimbursement and follows a 'first in, first out' payment methodology.

Professional Component with an E/M service: Interpretation (Professional Component) of radiology services assigned PC/TC Indicator 1 performed by the Same Individual Physician or other QHP on the same date as an E/M is considered included in the E/M; to be considered for additional reimbursement a written radiology interpretation report must be submitted (except certain fluoroscopic/ultrasonic guidance codes).

Sequencing and duplicate editing for global and component codes: When a global service and component codes exist in a series, duplicate editing will deny the component or global depending on which was submitted and paid first; modifiers 26/TC are not used to change inherent code intent in such series.

Modifier usage guidance: UnitedHealthcare will give separate consideration to duplicate or repeat submissions only when appropriate modifiers are appended per policy (including use of 59, XE, XP, XS, XU, 91 for repeat PC/TC 6 or 8 services; 76/77 for repeat procedure episodes; and other modifier rules as specified).

PC/TC indicator handling and attachments: Codes are categorized by CMS PC/TC indicators (including lists for PC/TC Indicator 1 with percentage splits, codes without RVU splits allowed at 100% for both components, gap‑fill codes, and ASCFS Addendum BB lists). Refer to the attached code lists for code‑specific documentation and reimbursement rules; use modifier 26/TC per indicator guidance.

Definition of duplicate/repeatIdentical CPT or HCPCS codes with PC/TC Indicator 1,2,3,4,6 or 8 on separate claim lines or different claims regardless of Maximum Frequency per Day

Modifier reviewUnitedHealthcare reviews modifiers (26, TC, 59/XE/XP/XS/XU/91, 76/77, etc.) to determine whether separate reimbursement is appropriate

inv-11: Reimbursement for components without RVU splits

Gap fill allowanceGap Fill Codes (PC/TC Indicator 1 without CMS‑developed RVUs) may be allowed at 100% of the Allowable Amount for both PC and TC when no RVUs exist or gap‑fill data unavailable

Data source for gap fillWhen available, UnitedHealthcare uses Relative Values from Optum The Essential RBRVS first quarter update for the current year

ApplicabilityApplies to codes CMS indicates may be carrier‑priced or for which CMS does not develop RVUs

Use modifiers 76 or 77 to identify repeat procedures performed at different episodes on the same day; do not use 76/77 to report multiple interpretations of the same EKG or x‑ray for quality control purposes. (See Q&A guidance.)
Use modifiers 59, XE, XP, XS, XU or 91 to indicate distinct or repeat laboratory services as appropriate; do not use 76/77 for laboratory repeats.
UnitedHealthcare will only give separate consideration to duplicate submissions when an appropriate modifier (for example 59, XE, XP, XS, XU, 91, 76, 77 as contextually appropriate) is appended per the policy rules.

Documentation Required

Documentation requirement for radiology interpretations billed with E/M

When a radiology interpretation (PC/TC Indicator 1) is billed the same day as an Evaluation and Management (E/M) service by the Same Individual Physician or Other QHP, the radiology interpretation is generally considered included in the E/M and not separately reimbursable. To be considered for separate reimbursement, the provider must submit a distinctly identifiable, signed, written radiology interpretation report that documents studies/procedures, findings using appropriate terminology, and an impression (conclusion/diagnosis). Reporting modifier 59, XE, XP, XS, XU or 91 in addition to modifier 26 does not remove the requirement for a separate signed written radiology report.

Include description of studies/procedures, any contrast/radiopharmaceuticals (dose, concentration, volume, route), medications, catheters, or devices used when not recorded elsewhere.
Document findings with appropriate anatomic, pathologic, and radiologic terminology.
Provide an Impression (conclusion or diagnosis).
Even when modifier 25 or distinct modifiers are reported for the E/M, the radiology interpretation itself still requires the separate signed written report for additional reimbursement.

IdentificationIdentified by appending modifier 26 or by reporting a stand‑alone PC code when applicable

inv-25: Technical Component (TC)

DefinitionTechnical Component (TC): the facility, equipment and technician portion of a Global Service, reported with modifier TC

IdentificationIdentified by appending modifier TC or by reporting a stand‑alone TC code when applicable

Inclusion in facility paymentTC performed in a facility setting is deemed included in the facility global payment and not separately reimbursable to the physician/QHP

inv-26: Facility POS list

Facility POS listPOS 19, 21, 22, 23, 26, 34, 51, 52, 55, 56, 57, 61 are considered facility for this policy

Non‑facility definitionAll other POS values are considered non‑facility for the purposes of this policy

Mobile unit exceptionMobile unit may report POS 15 when no facility claim has been submitted for same date; services performed in facility POS are included in facility payment

inv-27: Professional Component (PC)

DefinitionProfessional Component (PC): the physician or QHP work portion (supervision, interpretation, report) of the procedure, identified by modifier 26 or stand‑alone PC code

Clinical effectDirectly contributes to diagnosis and/or treatment and results in a written narrative report included in the medical record

Cost elementsRepresents physician work, practice overhead and malpractice expense

inv-28: Technical Component (TC)

DefinitionTechnical Component (TC): the performance (technician/equipment/facility) portion of the procedure, identified by modifier TC or stand‑alone TC code

Inherent codesFor stand‑alone codes, TC may be inherent in the code description and modifiers TC/26 are not used

Facility inclusionWhen performed in a facility, TC is typically included in the facility global payment and not reimbursed separately to physician/QHP

inv-29: Duplicate or Repeat Services

DefinitionDuplicate or Repeat Services: identical CPT or HCPCS codes assigned PC/TC Indicator 1,2,3,4,6 or 8 submitted for the same patient on the same date on separate claim lines or different claims

Reimbursement ruleOnly one physician or other QHP will be reimbursed for Duplicate or Repeat Services unless modifiers indicate distinct services per policy guidance

Modifier considerationUHC reviews modifiers such as 26, TC and 59/XE/XP/XS/XU/91, 76/77 to determine separate reimbursement

inv-30: Stand-alone Code

DefinitionStand‑alone Code: a code that describes a specific component (PC or TC) of a diagnostic test; PC and TC are inherent in stand‑alone code descriptions

ExampleSeries such as ECG codes: 93010 (PC), 93005 (TC), 93000 (global) illustrate stand‑alone coding

Modifier usageModifiers 26 or TC are not used to report services where intent is inherent in the code description

inv-31: Repeat procedures modifiers

Modifiers 76/77 purposeModifiers 76 and 77 must be used to identify repeat procedures performed at different episodes on the same day

Appropriate useUse when subsequent procedures show different findings that alter/contribute to diagnosis and treatment

Not for labsInappropriate to use 76/77 for repeat laboratory services; use 59, XE, XP, XS, XU or 91 as appropriate

inv-32: Laboratory repeat-service modifiers

Lab repeat modifiersModifiers 59, XE, XP, XS, XU or 91 are used to indicate repeat or distinct laboratory services

Inapplicability of 76/77Modifiers 76/77 are inappropriate for repeat laboratory services; separate consideration will not be given if 76/77 used for labs

ContextUse per AMA and CMS guidance as noted in policy Q&A and modifier guidance

inv-33: PC/TC Indicator

DefinitionPC/TC Indicator: CMS designation indicating whether a code describes a Professional Component, Technical Component, or Global test

Common indicatorsIndicator 1 = PC+TC (split eligible); Indicator 2 = PC only; Indicator 3 = TC only; Indicator 4 = Global test only; Indicator 6 = lab physician interpretation; Indicator 8 = physician interpretation codes; Indicator 9 = not applicable

Policy useUnitedHealthcare uses CMS PC/TC indicators to determine eligibility for separate PC and TC reimbursement and to apply ASCFS/pos specific rules

2026-01-12Policy List Update

Updated Professional/Technical Component Codes (PC/TC Indicator 1), Codes Subject to the PC/TC Concept Without RVU Splits, and Gap Fill Codes; archived history entries prior to 2024-01-12.

2026-01-01Policy List Update

Updated lists for Professional/Technical Component Codes (PC/TC Indicator 1), Codes Subject to the PC/TC Concept Without RVU Splits, Gap Fill Codes, Laboratory Codes with PC/TC Indicator 3 or 9, and ASCFS Addendum BB PC/TC Indicator 1 codes.

2025-11-23Policy List Update

Updated ASCFS Addendum BB PC/TC Indicator 3 codes list.

2025-07-13Policy List Update

Updated ASCFS Addendum BB PC/TC Indicator 3 codes list.

2025-06-29Policy List Update

Updated Laboratory Codes lists with PC/TC Indicator 3 or 9 and archived older history entries.

2025-03-30Policy List Update

Updated Laboratory Codes lists with PC/TC Indicator 3 or 9 and archived older history entries.

2025-01-26Policy List Update

Updated Professional/Technical Component Codes (PC/TC Indicator 1), Codes Subject to the PC/TC Concept Without RVU Splits, and Gap Fill Codes.

2025-01-12Policy List Update

Updated ASCFS Addendum BB PC/TC Indicator 1 codes list; archived history entries prior to 2023-01-12.

2025-01-01Policy List Update

Updated Professional/Technical Component Codes (PC/TC Indicator 1), Gap Fill Codes, Laboratory Codes with PC/TC Indicator 3 or 9, and Radiological Codes Requiring Attached Report.

2024-10-01Policy Section Update

Updated Professional Component with an Evaluation and Management Service and added Q&A items #6 and #7; added Radiological Codes Requiring Attached Report list.

2024-06-30Policy List Update

Updated Codes Subject to the PC/TC Concept Without RVU Splits.

2024-04-01Template Update

Transferred content to shared policy template for UnitedHealthcare Commercial and Individual Exchange plans and updated Application section.

1999-05-01Policy Implementation

Policy implemented by UnitedHealthcare Employer & Individual.

1999-02-10Policy Approval

Policy approved by the Clinical Review Committee.