0116-Modifiers TC and 26: Incorrect Coding

Issue Name
0116-Modifiers TC and 26: Incorrect Coding
Date
Review Type
Automated
Provider Type
Professional Services
MAC Jurisdiction
All A/B MACs

Description

HCPCS Codes with a PC/TC Indicator of "1" and billed with either 26 or TC in any modifier field should be paid at either the technical component or the professional component rate based on the modifier billed.  Overpayments occur when the applicable Medicare Physician Fee Schedule amount for Modifier TC and/or 26 are not applied.

Affected Codes

HCPCS Codes with a PC/TC Indicator of "1" as identified in the CMS MPFSDB

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.929- Post-Payment Review
4.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
5.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6.    42 CFR §405.986- Good Cause for Reopening  
7.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8.    Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §50.6- Physician Fee Schedule Payment Policy Indicator File Record Layout
9.    Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum - MPFSDB Record Layouts  20 - Professional Component (PC)/Technical Component (TC) Indicator https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf
10.    Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum - MPFSDB Record Layout and Field Descriptions; MPFSDB File Record Layout for 2018 and prior may be found on the CMS website: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched