changes in reimbursement - Billing professional and technical component -

Modifier 26

Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number.


Modifier TC

Technical Component. Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians.

However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.

Global service

Unmodified CPT codes are intended to describe both the technical and professional components of a service. The professional and technical components together are
referred to as the "global service."

“If the technical and professional components of the service are performed by the same provider, then it is not appropriate to report the components of the service separately.”

When the service is furnished to a hospital outpatient or inpatient, the facility bills the technical component, which includes the cost of equipment, supplies, technician salaries, etc.


If the interpreting physician is not paid by the facility for services but will instead be billing the carrier separately, the physician may bill only for the professional component.

“Hospitals must provide directly or under arrangements all services furnished to hospital outpatients. Therefore, if a specimen (e.g., tissue, blood, urine) is taken from a hospital patient, the facility or technical component (TC) of the diagnostic test must be billed by the hospital. Only in cases where the patient leaves the hospital and obtains the service elsewhere is the hospital not required to bill for the service…At the request of the industry, the implementation of this rule was delayed to allow independent laboratories and hospitals sufficient time to negotiate arrangements…through February 29, 2012.”

 Reimbursement Guidelines

Procedures that are comprised of both a technical and professional component are identified on the National Medicare Physician Fee Schedule Database (MPFSDB) in Field 20 with a Professional Component (PC)/Technical Component (TC) Indicator of “1”. It is never appropriate for the technical and professional components to be unbundled and reported separately under the same TIN number (whether on separate line items of a single claim or on separate claims).  When determining if the technical and professional components were performed by the “same provider” or by different providers, if both components will be billed under the same tax ID number (TIN) then both components were performed by the same provider and are not eligible to be reported as separate components. Instead the global service should be billed without modifier TC or 26.

Example:

If the x-ray equipment is jointly owned by the physicians in a clinic, then the clinic must obtain a separate TIN number in order to separately submit the technical component (TC) of the service.

If the clinic has not obtained a separate TIN (and a separate contract with Insurance to be participating), then the global service must be billed by the interpreting clinic physician. The clinic must manage the equitable distribution of reimbursement for the technical component of the service internally through accounting and the joint ownership agreement for the shared equipment.


When the technical and professional components of a procedure are unbundled and billed to Insurance under the same TIN, the Insurance claims processing system will process the component procedures in a variety of ways (due to system constraints).

• Often the system will deny one component as a subset to the other component, resulting in an underpayment. In these situations, no override or bypass will be given for the edit.

Insurance requires a corrected claim with the procedure billed as a global service(without -TC or -26 modifier) for any adjustment or additional reimbursement to be
considered.

• The system may rebundle the component services into the global service. If this occurs, the claim will not be adjusted to process the components on separate lines. If the components were provided by separate entities, each component must be billed under a separate TIN on separate claims, and a corrected claim set will be required.

• In some cases both components may be separately allowed, but the total allowed fee will not be any higher than if the service had been correctly billed as the global service.

Only the components that have been actually performed by the billing provider may be billed to Insurance. If only one of the components has been performed, charges may not be submitted to Insurance for the component that has not been performed. The instructions in CMS Transmittal 1892/CR6733 are both optional and conditional, and do not apply to claims submitted to Insurance.

While CMS does sometimes instruct providers to re-bill the service as separate professional and technical component procedure codes, our research indicates this is specifically related to the calculation of CMS bonus payments in a health professional shortage area (HPSA), and does not apply to billing to commercial carriers such as Insurance. Submitting Only the Professional Component

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1, 6, or 8 (see field 20 on the MPFSDB) will be allowed with modifier 26 appended.

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 7, or 9 will be denied when submitted with modifier 26 appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.

Submitting Only the Technical Component

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1 (see field 20 on the MPFSDB) will be allowed when modifier TC is appended.
• Procedure code with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 6, 7, 8, or 9 will be denied when submitted with modifier TC appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.

Services Reported in a CMS POS 24 (Ambulatory Surgical Center) 

CMS guidelines, UnitedHealthcare Community Plan will not reimburse physicians or other health care professionals for the Technical Component of services included in the Ambulatory Surgery Center Fee Schedule (ASCFS) Addendum BB and reported with a CMS POS 24 as the ambulatory surgical center (ASC) is reimbursed for the Technical Component.

The Technical Component of services reported on a CM-1500 claim form with an SG modifier (Ambulatory surgical center [ASC] facility service) is not reimbursed as a professional claim.

 Claim lines reported with modifier SG indicate a facility charge and are reimbursed as a facility claim. PC/TC Indicator 1 Codes 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 (no modifier), the Technical Component of the code will not be reimbursed.

  When reported with modifier TC, the code will not be reimbursed. PC/TC Indicator 3 Codes

Codes included in the ASCFS Addendum BB PC/TC Indicator 3 Codes list will not be reimbursed as they represent Technical Component services only.

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