CurrentColorado Rocky Mountain Health PlansPolicy 2025R9053A

CMS 1500 reimbursement modifiers guidance for UnitedHealthcare Medicare Advantage

Governs reimbursement and appropriate use of specific CPT/CMS modifiers on claims billed on the CMS 1500 form for UnitedHealthcare Medicare Advantage plans; applies to all network physicians and other qualified health care professionals submitting CMS 1500 (or electronic equivalent) claims.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 reimbursement modifiers guidance for UnitedHealthcare Medicare Advantage

Policy CodePolicy 2025R9053A

Change TypeNo material change

Effective Date12/01/2025

Next Review Date

Key ActionDo not report modifiers 27, 73, 74, or PO on CMS 1500 claims submitted by physicians or other qualified health care professionals; such claims will be denied when these ASC/outpatient-hospital-only modifiers are appended.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4modifiers listed in policy

CMS 1500claim form this policy applies to

All Medicare Advantage productsproduct applicability

Denial Rule for Specific Modifiers

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Modifier Groups and Billing Status

Modifiers subject to denial when billed by physician/other professionalModifierNot Covered

27	Regional anesthesia/analgesia (modifier listing per policy)
73	Discontinued outpatient hospital/ambulatory surgery center procedure prior to anesthesia
74	Discontinued outpatient hospital/ambulatory surgery center procedure after anesthesia
PO	Services furnished in ambulatory surgical center

Billing and Documentation Requirements

Billing Rule

Do not append ASC/outpatient-hospital-only modifiers on professional CMS 1500 claims

Do not report modifiers 27, 73, 74, or PO on claims submitted by physicians or other qualified health care professionals on the CMS 1500 form. Codes appended with these modifiers will be denied when reported by physicians or other non-ASC/outpatient-hospital providers.

Documentation Required

Verify place of service and appropriate modifier use

Ensure the place of service and billing entity (ASC or outpatient hospital versus professional billing on CMS 1500) support use of these modifiers. For member-specific benefit questions, contact the customer service number on the member ID card.

Policy Scope and Context

This reimbursement policy applies to UnitedHealthcare Medicare Advantage plans and governs appropriate reporting of specific CPT/CMS modifiers on claims submitted using the CMS 1500 form (or electronic equivalent). UnitedHealthcare Medicare Advantage will deny codes appended with the listed modifiers when those modifiers are reported by a physician or other qualified health care professional billing on the CMS 1500 (i.e., professional) claim form rather than by an ambulatory surgical center (ASC) or outpatient hospital.

The policy lists ASC and outpatient-hospital–designated modifiers that are not payable when appended to professional claims: 27, 73, 74, and PO. Providers should ensure the place of service and billing entity support use of these modifiers. For member-specific benefit questions, contact the customer service number on the member ID card.

UnitedHealthcare Medicare Advantage may modify this policy at any time to comply with changes in CMS policy and national coding guidelines; providers are encouraged to monitor CMS resources and UnitedHealthcare communications for updates.

Policy Metadata

Document metadata

Effective date12/01/2025

Last review12/01/2024

Next review

Policy number2025R9053A

SubjectCMS 1500 reimbursement modifiers guidance for UnitedHealthcare Medicare Advantage

StatusCURRENT

Scope summaryGoverns reimbursement and appropriate use of specific CPT/CMS modifiers on claims billed on the CMS 1500 form for UnitedHealthcare Medicare Advantage plans; applies to all network physicians and other qualified health care professionals submitting CMS 1500 (or electronic equivalent) claims.

Supplemental stats

Modifiers listed in policy4

Claim form this policy applies toCMS 1500

Product applicabilityAll Medicare Advantage products

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 reimbursement modifiers guidance for UnitedHealthcare Medicare Advantage

Policy CodePolicy 2025R9053A

Change TypeNo material change

Effective Date12/01/2025

Next Review Date

SourceLink

On This Page

OpenPayer

CMS 1500 reimbursement modifiers guidance for UnitedHealthcare Medicare Advantage

Denial Rule for Specific Modifiers

Modifier Groups and Billing Status

Billing and Documentation Requirements

Policy Scope and Context

Defined Terms

Policy Metadata

CMS 1500 reimbursement modifiers guidance for UnitedHealthcare Medicare Advantage

Denial Rule for Specific Modifiers

Modifier Groups and Billing Status

Billing and Documentation Requirements

Policy Scope and Context

Defined Terms

References and Related Policies

Policy Metadata