CurrentColorado Rocky Mountain Health PlansPolicy 2026R0111B

UnitedHealthcare Commercial and Individual Exchange Reimbursement Policy — CMS 1500 Modifier Guidance

Defines UnitedHealthcare reimbursement guidance for use of CPT/HCPCS modifiers on services billed on the CMS-1500 (or electronic equivalent) for UnitedHealthcare Commercial and Individual Exchange benefit plans and applies to all network and non-network providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 modifier reimbursement guidance for UnitedHealthcare Commercial and Individual Exchange

Policy CodePolicy 2026R0111B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must submit accurate claims on the CMS-1500; UnitedHealthcare may modify this policy by publishing a new version.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1500form governed (CMS-1500)

Commercialapplies to plan type

Individual Exchangeapplies to plan type

~70+modifiers referenced

historypolicy history entries

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Modifier and CMS-1500 Coverage Rules

Modifier coverage criteria

Modifier-specific guidance and cross-references to related reimbursement policies (e.g., anesthesia, CCI editing, global days, MPPR, laboratory services). For full application, refer to the specific reimbursement policy noted for each modifier.

An overview: modifiers indicate that a service was altered by specific circumstances without changing the code definition; use this document as a reference and consult the specific reimbursement policy or the Procedure to Modifier Policy for complete application.

Source guidance: AMA/CMS definition and overall policy purpose.

E/M-related

Modifier 24 — only used with E/M services; see CCI Editing and Global Days reimbursement policies.
Modifier 25 — used only with E/M codes; do not append to the surgical procedure code(s); see CCI Editing, Global Days, Injection and Infusion, Preventive Medicine & Screening, Prolonged Services and rebundling policies.
Modifier 22 — increased procedural services guidance and cross-reference to anesthesia, increased procedural services, obstetrical, robotic assisted surgery reimbursement policies; generally should not be appended to an E/M service.

Distinct procedural service modifiers

Modifier 59 — used to identify a distinct procedural service; see CCI Editing and related reimbursement policies for appropriate use.
HCPCS subsets XE/XP/XS/XU — selective identification of -59 subsets; used to indicate distinct procedural circumstances per cross-referenced policies.

Laboratory services

Modifiers applicable to laboratory services and repeat testing rules include 90, 91, 92 and XE/XP/XS/XU; follow laboratory-specific reimbursement policy for repeat testing and TC/PC handling.

Telehealth/Virtual Health

Modifiers for telehealth/virtual health include 95, G0, GQ, GT; refer to Provider Based Billing and telehealth reimbursement guidance when applicable.

MPPR and multiple procedure rules

Multiple Procedure Payment Reduction (MPPR) references include modifiers such as 26, 50, 51, 53, 62, 66, 78-82, AS and TC across diagnostic imaging, cardiovascular/ophthalmology and medical/surgical MPPR policies.

Anatomical and bilateral modifiers

Anatomical modifiers (LT, RT, E1–E4, FA, F1–F9, TA, T1–T9, LC, LD, LM, RC, RI, etc.) have specific requirements and interactions with CCI editing, maximum frequency per day and other frequency limits; consult the anatomical modifier and CCI Editing reimbursement sections.

Modifier groups enumerated in this policy map to specific reimbursement topics (e.g., Professional/Technical Component, Rebundling, Prolonged Services, Once-in-a-Lifetime procedures); use the referenced reimbursement policy for detailed application.

See modifier reference tables for mapping of modifiers to policy topics.

CMS-1500 reimbursement and modifier rules

Reimbursement rules, modifier handling, and select billing guidance for CMS-1500 submissions.

Claims submission responsibility: providers are responsible for submission of accurate claims; UnitedHealthcare may use discretion in applying this policy and may modify it by publishing a new version.

Operational responsibility for claim accuracy.

SG modifier handling: Services reported on a CMS-1500 form with an SG modifier are treated as facility services and are not processed as professional claims; submitters should follow facility claim handling as applicable.

Q&A clarifies SG modifier treatment.

Services and modifiers not reimbursable to professionals

Specific modifiers indicate services not reimbursable to healthcare professionals (examples listed in policy include 27, 73, 74, PO, H9, HU, HV, HW, HX, HY, HZ, QJ, SE, SL, TR); consult the 'Services and Modifiers Not Reimbursable to Healthcare Professionals' reimbursement policy for the full list and application.

Professional/Technical and other modifier groupings

Modifier and Code References

Selected Modifiers (neutral)Modifier

59	Distinct Procedural Service
XE	Separate Encounter - Independent Procedure, subset of -59
XP	Separate Practitioner, subset of -59
XS	Separate Structure, subset of -59
XU	Unusual Non-Overlapping Service, subset of -59
TC	Technical Component
76	Repeat Procedure by Same Physician or Other Qualified Health Care Professional

Additional Modifiers (neutral)Modifier

77	Repeat Procedure by Another Physician
90	Reference (Outside) Laboratory
91	Repeat Clinical Diagnostic Laboratory Test
92	Alternative Laboratory Platform Testing
50	Bilateral Procedure
52	Reduced Services
E1	Upper Left, Anatomic Modifier
E2	Lower Left, Anatomic Modifier
E3	Upper Right, Anatomic Modifier
E4	Lower Right, Anatomic Modifier

Maximum Frequency / Laboratory / Professional/Technical Component ModifiersModifier

59	Distinct Procedural Service
76	Repeat Procedure by Same Physician
77	Repeat Procedure by Another Physician
90	Reference (Outside) Laboratory
91	Repeat Clinical Diagnostic Laboratory Test
92	Alternative Laboratory Platform Testing
XE	Separate Encounter - Independent Procedure
XP	Separate Practitioner
XS	Separate Structure
XU	Unusual Non-Overlapping Service

Maximum Frequency Per Day / Professional-Technical & Anatomical ModifiersModifier

50	Bilateral Procedure
59	Distinct Procedural Service
76	Repeat Procedure by Same Physician
91	Repeat Clinical Diagnostic Laboratory Test
E1	Anatomical Modifier E1
E2	Anatomical Modifier E2
E3	Anatomical Modifier E3
E4	Anatomical Modifier E4
LC	Left Circumflex Artery (example anatomical)
LD	Left Distal (example anatomical)

1–10 of 38

1/4

Modifier Reduction / Modifier-specificModifier

52	Reduced Services
CT	Complexity/Modifier Reduction
FX	Facility Exchange
FY	Financial Adjustment
SU	Subsequent Encounter

Maximum Frequency Per Day modifiers

Claims Submission & Modifier Handling for Providers

Documentation Required

Claims submission responsibility

You are responsible for submission of accurate claims. UnitedHealthcare may use reasonable discretion in interpreting and applying this policy and may modify it at any time by publishing a new version of the policy.

Submit claims that accurately describe the health care services provided using the appropriate codes and modifiers.
Be aware UnitedHealthcare may apply discretion based on coding methodology, benefits design, regulatory requirements, and system constraints.
Monitor the UnitedHealthcare policy website for updates, as the policy may be modified at any time.

Billing Rule

SG modifier treated as facility claim

Key Terms

inv-09: Modifier

DefinitionA modifier provides the means to report or indicate that a service or procedure performed has been altered by some specific circumstance but not changed in its definition or code.

PurposeMay provide additional information such as repeat performance, unusual events, multiple physicians, or multiple locations.

Reference guidanceFor appropriate use with individual CPT/HCPCS codes, refer to the Procedure to Modifier Policy as noted in the document.

inv-10: SG modifier

SG modifier meaningWhen reported on a CMS-1500 form, the SG modifier indicates facility services rather than professional services.

Claim treatmentClaims submitted on a CMS-1500 with an SG modifier are treated as facility claims, not professional claims.

Policy Revision History

2026-03-06Policy Version ChangeLatest

Removed the verbiage from Q&A section; history entries prior to 2024-03-06 were archived.

2026-02-01Policy Version Change

Policy version change recorded.

2025-01-07Policy Version Change