UHC – Commercial Policy Policy Number 2021R0012E Professional/Technical Component Policy, Professional

Policy List Changes: Codes Subject to the PC/TC Concept Without RVU Splits; Laboratory Codes with a PC/TC Indicator 3 or 9

UnitedHealthcare utilizes the CMS National Physician Fee Schedule (NPFS) PC/TC Indicators 3 or 9 to identify laboratory services that are not reimbursable to a Reference Laboratory or Non-Reference Laboratory in a facility setting.

 

UnitedHealthcare will not reimburse a Professional Component when a diagnostic laboratory service is provided either manually or with automated equipment, as these codes are not subject to the PC/TC concept or are Technical Component only codes. UnitedHealthcare follows CMS PC/TC indicators in determining which services do not qualify for Professional Component reimbursement:

• CMS PC/TC Indicator 3 (Technical Component Only Codes)

• CMS PC/TC Indicator 9 (PC/TC Concept Not Applicable) Laboratory Codes with a PC/TC Indicator 3 or 9

 

Note: UnitedHealthcare will make an exception to this policy for reproductive medicine procedures 89250-89398 when the facility laboratory is not equipped to perform these specialized services and refers them to a reproductive laboratory. In the event that both a facility and a Reference Laboratory report the same service on the same day for the same member, only the facility laboratory may be reimbursed.

Source: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-Professional-Technical-Component-Policy.pdf