Cigna to Stop Reimbursement for Professional Component of Clinical Pathology Claims

On April 12, 2021 Cigna issued an update to their Modifier 26 Professional Component policy, stating codes inappropriately billed with the 26 modifier will be denied effective 7/11/2021. XiFin interprets this to mean Cigna will discontinue reimbursing the Professional Component of Clinical Laboratory (PCCL) claims. 

The reimbursement policy for policy M26 (Modifier 26 Professional Component) states:

“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 NPFSRVF lists all CPT codes and the PCTC Indicator outlines the appropriate modifiers applicable to each CPT code.  Clinical lab codes have an indicator of 9, meaning the concept of a technical or professional component does not apply:

AP codes have a PCTC indicator of 1, indicating this is a diagnostic test consisting of both technical and professional components:

While this policy has been in effect since 5/22/2018, the latest announcement appears to be the final nail in the coffin for Cigna PCCL reimbursement. 

The entire Reimbursement Policy can be found here Professional Component (cigna.com).

 

Source: https://static.cigna.com/assets/chcp/secure/pdf/resourceLibrary/clinReimPolsModifiers/Notifications/modifier_26_professional_component.pdf