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Effective October 1, 2017, Blue Cross & Blue Shield of Mississippi (BCBSMS) will implement component billing guidelines as outlined in this policy for diagnostic services. Claims for diagnostic services will be reviewed for billing appropriateness and may be subject to rejection/denial of one or more services, and/or requesting of medical documentation. Providers must ensure that diagnostic services are reported utilizing the most accurate information including, but not limited to, the current CPT/HCPCS procedure codes, ICD-10 diagnosis codes, modifiers, and place of service codes.
This coding policy applies to services reported with Professional and Technical Component Modifiers. The Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File should be used to identify CPT/HCPCS codes which are appropriate to be filed with a Professional and/or Technical Component based on the NPFS PC/TC indicators. This file can be located on CMS’s website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html
Definitions:
Global Service (No Modifier 26 or TC)
A Global Service includes both a Professional Component and a Technical Component
(a total or complete procedure). When a physician or other healthcare provider bills a Global Service, he or she is submitting for both the Professional Component and the Technical Component of that code. Submission of a Global Service asserts that the same individual physician or other healthcare provider provided the supervision, interpretation and report of the professional services as well as the technician, equipment, and the facility needed to perform the procedure. In appropriate circumstances, the Global Service is identified by reporting the appropriate Professional Component / Technical Component split eligible procedure code with no modifier attached or by reporting a Standalone code for Global test only services.
Professional Component (CPT Modifier 26)
The Professional Component represents the physician or other healthcare provider work portion (physician work/practice overhead/malpractice expense) of the procedure. The Professional Component is the physician or other healthcare provider supervision and interpretation of a procedure that is personally furnished to an individual patient, results in a written narrative report to be included in the patient’s medical record, and directly contributes to the patient’s diagnosis and/or treatment. In appropriate circumstances, it is identified by appending modifier 26 to the designated procedure code or by reporting a standalone code that describes the Professional Component only of a selected diagnostic test.
Modifier 26: Professional Component
Certain procedures are a combination of a physician or other qualified healthcare professional component and a technical component. When the Professional Component is billed separately, the serviced may be identified by adding modifier 26 to the usual procedure number. A written report is documented by the physician who renders this service.
Technical Component ( HCPCS Level II Modifier TC)
The Technical Component is a facility charge and is not billed separately by a physician or other qualified healthcare provider. The Technical Component includes the cost of the equipment, supplies, and technician’s salaries. The TC modifier is used for procedures that have a Professional and Technical Component and the Technical Component is performed by one provider and the Professional Component by another.
Modifier TC: Technical Component
Certain procedures are a combination of a physician or other qualified healthcare Professional Component and a Technical Component. When the Technical Component is billed separately, the service may be identified by adding the modifier ‘TC’ to the usual procedure number.
Standalone Procedure Code
A Standalone Code describes a specific component of a selected diagnostic test. There is an associated code that describes the Professional Component only of the diagnostic test, an associated code that describes the Technical Component only, and another associated code that describes the global test only. Modifiers -26 and/or -TC are not appropriate for usage with standalone codes.
Place of Service (POS) Codes
Many of the diagnostic services, including radiology services provided by physicians/providers which contain both a Technical Component and a Professional Component are often furnished in different settings. Providers should use the appropriate POS code when reporting to BCBSMS.
The place of service code (POS) on professional claims (ANSI 837P and CMS 1500) must be reported based on where the patient physically received face-to-face-services, except in those cases where the patient is a registered inpatient or an outpatient of a hospital. In these instances, the POS code for the inpatient hospital (POS code 21) or outpatient hospital (POS code 22) is used, irrespective of where the face-to-face encounter occurs. For non face-to face services, such as interpretation of diagnostic test results, the POS code of the setting in which the patient received the technical portion of the service should be reported.
Policy Guidelines
BCBSMS uses the
to determine whether a procedure code is eligible for separate Professional Component and Technical Component services reimbursement. The NPFS Relative Value File is updated quarterly.
When a provider is billing only for the Professional Component of a procedure, Modifier 26 must be reported, as appropriate.
When a provider is billing only for the Technical Component of a procedure, Modifier TC must be reported, as appropriate.
Diagnostic services, including radiology procedures may be reported by facilities, physicians, and other qualified healthcare providers. Procedure code descriptors indicate whether the service is considered the Professional Component service, Technical Component service, or Global service.
When the code reported is considered a global code and the Professional and Technical Components of the procedures are rendered by different providers, the appropriate Modifiers (-TC and/or -26) must be reported with the global code by each provider.
When the code reported is considered a global code and the Professional and Technical Components of the procedures are rendered by the same provider, it is considered a Global Service and must be reported without any modifiers.
BCBSMS will reimburse codes appropriately filed separately with the Professional Component -26 and/or Technical –TC Modifiers. CPT/HCPCS codes assigned an indicator of ‘1’ in the PC/TC field of the NPFS are eligible for reporting these Components separately.
Examples: Codes G0235, 72156, 88125, 88342 and 88305 are valid to be filed separately with Modifiers -26 and/or –TC as appropriate.
BCBSMS will
not
allow codes to be filed with Modifier –TC when the CPT/HCPCS code is assigned an indicator of ‘6’ in the PC/TC field on the NPFS. Modifier -26 is allowed with these codes.
Examples: Codes G0452, 83020, 84181, and 86335 are valid to be filed with Modifier -26. Modifier –TC is not valid with these codes.
BCBSMS will
not
allow reimbursement for services where there is no separate Professional Component and/or Technical Component applicable to the service. These are CPT/HCPCS codes assigned a 0, 2, 3, 4, 5, 7, 8, and 9 in the PC/TC field on the NPFS.
For example, a complete blood count (CBC) with automated differential WBC is billed with CPT code 85004. The Professional Component and Technical Component modifiers do not apply to this code; therefore it is not acceptable to bill with an add-on charge as 85004-26.
Examples: Codes 77417, 80156, 85025, 80050, and 86777 are not valid to be filed with Modifiers -26 or –TC. These codes do not carry a separate Technical and Professional Component.
Standalone Procedure codes should be reported without the use of Modifiers -26 and/or –TC. These codes are assigned an indicator of ‘2’ (Professional service), ‘3’ (Technical service) or ‘4’ (Global service) in the PC/TC field on the NPFS.
The place of service code (POS) on professional claims (ANSI 837P and CMS 1500) must be reported based on where the patient physically received face-to-face-services, except in those cases where the patient is a registered inpatient or an outpatient of a hospital. In these instances, the POS code for the inpatient hospital (POS code 21) or outpatient hospital (POS code 22) is used, irrespective of where the face-to-face encounter occurs. For non face-to face services, such as interpretation of diagnostic test results, the POS code of the setting in which the patient received the technical portion of the service should be reported.
None.
The coding guidelines outlined in Component Billing for Diagnostic Clinical Laboratory Service Coding Policy should not be used in lieu of the Member's specific benefits plan language.
5/23/2016: Policy Added.
2/03/17: Policy Modified
10/1/17: Policy Effective
Coding with Modifiers, 4th Edition. 2011. Pages 69-76; 183-191. American Medical Association.
Technical vs Professional Component, CPT Assistant May 1999. Page 1. American Medical Association.
Use of CPT Modifiers 76, 78 and 79 CPT Assistant September 2010. Page 6. American Medical Association.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf
Centers of Medicare and Medicaid Services, MLN Article 7631.
Centers of Medicare and Medicaid Services, Physician Fee Schedule (PFS) Relative Value Files.