May 2, 2019
It is important to know if the code can be split for a professional component or a technical component before billing. By code description, procedure codes are considered:
- 100% professional
- 100% technical
- 100% global
- or the concept isn’t applicable and professional or technical component modifiers are NOT appropriate.
Why is this important?
If Premera has already paid for a global submission of a code, a claim edit will deny any subsequent separate professional or technical submission of the same service. If we’ve already paid for a separate professional or separate technical submission, we will not pay for a subsequent global submission of the service. These criteria are enforced through our claims editing system.
Use the Center for Medicare and Medicaid Services (CMS) National Physician Fee Schedule Relative Value file designation to find out if a CPT or HCPCS code has a “professional or technical split”. Using the PC/TC indicator column of the file, you can see which codes can be billed with either modifier 26-Professional component or modifier TC-technical component.
- Procedures assigned a PC/TC indicator of the following can be billed with modifier 26-Professional Component:
- 1 – Diagnostic tests for Radiology Services
- 6 – Laboratory Physician Interpretation Codes
- Procedures assigned a PC/TC indicator of the following can be billed with the modifier TC-Technical component:
- 1 – Diagnostic tests for Radiology Services
If a code with a PC/TC indicator of 1 or 6 is not billed with either modifier 26 or TC, that procedure will be considered a “global” submission of the service, meaning the provider rendered both the professional and technical components of the service.
All other PC/TC indicator flags (0, 2, 3, 4, 7, 8, or 9) represent codes that by definition/code description are technical only (no modifier needed), professional only (no modifier needed), global only or the PC/TC concept is not applicable. When these codes are billed with either modifier 26 or TC, they will encounter an edit and be denied reimbursement.
We will soon be performing cross functional editing on submissions of professional and technical components to identify possible double billing and/or double payment.
To learn more about professional and technical billing of applicable codes, review the Payment Policies on “Modifier 26-Professional Component” and “Modifier TC-Technical Component” for further details. Also, the CMS National Physician Fee Schedule can be found at this link, has the PC/TC flagged codes.