Policy No: 106
Originally Created: 02/01/2009
Last Reviewed: 05/01/2019
Last Revised: 06/01/2018
Effective Date: 07/01/2019
This policy applies to all physicians, other qualified health care professionals, hospitals and other facilities.
CPT Modifier 26
Current Procedural Terminology (CPT®) modifier 26 represents the professional (provider) component of a global service or procedure and includes the provider work, associated overhead and professional liability insurance costs. This modifier corresponds to the human involvement in a given service or procedure.
HCPCS Level II modifier TC
Health Care Common Procedure Coding System (HCPCS) Level II modifier TC represents the technical component of a global service or procedure and includes the cost of equipment and supplies to perform that service or procedure. This modifier corresponds to the equipment/facility part of a given service or procedure.
A global service
A global service represents a complete service or procedure that includes both the professional and technical components.
Centers for Medicare & Medicaid (CMS) PC/TC indicators are found in the CMS National Physician Fee Schedule Relative Value File. Values which are currently in the CMS file are:
0 - Physician service only codes. The concept of PC/TC does not apply.
1 - Diagnostic tests for radiology services. Both modifiers 26 and TC can be used with these codes.
2 - Professional component only codes. Modifiers 26 and TC cannot be used with these codes.
3 - Technical component only codes. Modifiers 26 and TC cannot be used with these codes
4 - Global test only codes. These are selected diagnostic tests that describe a) the professional component of the test only, and b) the technical component of the test only. Modifiers 26 and TC cannot be used with these codes.
5 - Incident to codes. These are services covered incident to a physician's service when provided by auxiliary personnel employed by and working under physician. Modifiers 26 and TC cannot be used. Services cannot be paid when they are rendered to patients in inpatient or outpatient hospital setting.
6 - Laboratory physician interpretation codes. Actual performance of the test is paid under the lab fee schedule. Modifier TC cannot be used. Physician performing interpretations of these codes must be billed with modifier 26. These services can be paid under the physician fee schedule if they are furnished to a patient by a hospital pathologist or an independent laboratory.
7 - Physician therapy service, for which payment may not be made when the service is billed by an independently practicing physical or occupational therapist to a patient in an inpatient or outpatient hospital setting.
8 - Physician interpretation codes. This is for physician interpretation of an abnormal smear for hospital inpatient. No TC billing is recognized. The actual test is paid through inpatient PPS rate.
9 - Not applicable. The concept of TC/PC does not apply.
CMS designates which procedure codes are valid for use with modifier 26 and modifier TC. Our health plan utilizes these CMS designations in determining procedure code/modifier combinations that are valid for our use. Procedure code/modifier combinations that are considered not valid for our health plans use will be denied.
In the event there is a conflict between CMS and the American Medical Association (AMA), AMA guidelines take precedence.
Correct coding guidelines require that modifier 26 be used when the professional component of a global service is the only service provided (i.e. supervision and/or interpretation codes.)
Modifier 26 must be reported with codes having a CMS PC/TC indicator of 1 by the interpreting physicians or other health care professionals if the service is performed in a CMS defined facility place of service setting. The facility will be reimbursed for the technical component portion of the service unless otherwise limited in the facility contract.
Correct coding guidelines require that modifier TC be used when the service provided represents only the equipment or facility component of a global service and not the professional component of the same service. Hospitals frequently provide only the technical component of some services. Hospitals are not currently required to submit the TC modifier, but will be reimbursed as if the TC had been billed.
A global procedure code should be reported when a single provider or entity performs both the professional and technical components of a given service.
Centers for Medicare & Medicaid Services (CMS), National Physician Fee Schedule Relative Value File
American Medical Association. Appendix A: Modifiers, Current Procedural Terminology (CPT). AMA Press
Centers for Medicare & Medicaid Services (CMS). Appendix A: Modifiers. Health Care Procedure Coding System (HCPCS). Ingenix
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