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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that A/B Medicare Administrative Contractors (MACs) (B) may not pay for the technical 
component (TC) of radiology services furnished to hospital patients. Payment for physicians radiological 
services to the hospital, e.g., administrative or supervisory services, and for provider services needed to 
produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service. Radiology and 
other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment 
System (OPPS) to the hospital. This applies to bill types 12X and 13X that are submitted to the AB MAC (A). 
Effective April 1, 2006, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for 
radiology services. A medical necessity review was not completed as the denial was not for medical necessity. 
The plan is upholding the denial as the provider did not bill as required by Medicare coding regulations. Per the 
2023 National Physician Fee Schedule Relative Value File January Release CPT code 88305, Modifier field 
entry is depicted with a Blank, TC and 26 and the PCTC Indicator field is entered with a 1. You can find this 
information in the Medicare Claims Processing Manual Chapter 13  Radiology Services and Other Diagnostic 
Procedures 20.2  Technical Component (TC) 20.2.1  Hospital and Skilled Nursing Facility (SNF) Patients. 
 
The rules say that when the CPT code is billed without a modifier (a blank) this denotes the global service. You 
can find the information in the Medicare Claims Processing Manual, Chapter 23  Fee Schedule 
Administration and Coding Requirements, Section, 50.6  Physician Fee Schedule Payment Policy Indicator 
File Record Layout. 
 
The rules say that the CMS Medicare Physician Fee Schedule Database (MPFSDB) includes the total fee 
schedule amount, related component parts, and payment policy indicators. The record layout is provided in the 
Addendum below. 50.6  Physician Fee Schedule Payment Policy Indicator File Record Layout Field Name & 
Description  Modifier, for diagnostic tests, a blank in this field denotes the global service and the following 
modifiers identify the components: 26 = Professional component, TC =Technical component. Field Name & 
Description  Professional Component (PC)/Technical Component (TC) Indicator, 1= Diagnostic tests or radiology services: This indicator identifies codes that describe diagnostic tests, e.g., pulmonary function tests, 
or therapeutic radiology procedures, e.g., radiation therapy. These codes generally have both a professional and 
technical component. Modifiers 26 and TC can be used with these codes. The total RVUs for codes reported 
with a 26 modifier include values for physician work, practice expense, and malpractice expense. The total 
RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only. 
The total RVUs for codes reported without a modifier equals the sum of RVUs for both the professional and 
technical component. You can find this information in the Medicare Claims Processing Manual, Chapter 23  
Fee Schedule Administration and Coding Requirements, Section 30.2 MPFSDB Record Layout. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.