Cigna to cease payment for professional component of clinical pathology

April 16, 2021

Cigna, one of the last remaining payers that reimburses the professional component of clinical pathology, will look to officially end that practice this summer, according to an update posted April 12.

In the update to its Modifier 26 Professional Component Policy, Cigna states codes inappropriately billed with a 26 modifier will be denied beginning July 11, 2021. Further reading appears to show this will include the PC for clinical pathology claims.

The policy officials states the following:

“Cigna provides separate reimbursement for the professional component of the global fee at the fee schedule or other allowed amount when modifier 26 is appended correctly as determined by the Professional Component/Technical Component (PC/TC) indicators in the CMS Payment Policies provided in the National Physician Fee Schedule Relative Value File (NPFSRVF).”

The file lists all CPT codes and the PCTC indicator shows the appropriate modifiers for each code. Clinical pathology codes have an indicator of 9, meaning the concept of a technical or professional component is not recognized for these services.

Conversely, AP codes have a PCTC indicator of 1, meaning both the technical and professional components of these tests may be recognized distinctly.

Below is further instruction Cigna provided regarding appropriate use of a 26 modifier:

Correct Use of Modifier 26

  • Modifier 26 is appended when a physician provides the professional component only of the global fee and when the physician prepares a written interpretation and report.
  • Modifier 26 should only be appended to codes which are listed in the CMS NPFSRVF as modifier 26
  • appropriate.

Incorrect Use of Modifier 26

  • Modifier 26 is not appended when a facility/institution/physician owns the equipment, purchases the supplies, employs the technologist to perform the tests and employs the physician to interpret the tests. These features represent the global fee.
  • Modifier 26 is not appended when a procedure does not have a technical component. Example: CPT® code 76140-Consultation on X-ray examination made elsewhere, written report. Modifier 26 would not be appended since the description of the code already indicates it is the professional component.
  • Modifier 26 should not be appended to any code which is not listed in the CMS NPFSRVF as modifier 26 appropriate.

Please reach out to us directly at 517-486-4262 if you have questions regarding this change in reimbursement.

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