CurrentColorado Rocky Mountain Health PlansPolicy 2026R5006A

CMS-1500 coding and reimbursement for nonphysician health care professional services

Reimbursement policy governing correct coding methodology and payment for services billed on the CMS-1500 (and electronic equivalent) with emphasis on use of CPT/HCPCS codes by nonphysician health care professionals vs physicians; applies to all products and providers submitting CMS-1500 claims to UnitedHealthcare.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS-1500 coding and reimbursement for nonphysician health care professional services

Policy CodePolicy 2026R5006A

Change TypeCode list and version updates

Effective DateJan 1, 2026

Next Review Date

Key ActionDo not report nonphysician-specific CPT/HCPCS codes when the performing provider is a Physician; Physicians must report equivalent services using appropriate E/M or physician-level codes.

SourceLink

POLICY UPDATE CHANGES

Code list was updated as reflected in the History section (1/1/2025 entry indicates code list update).

Policy version change effective 1/1/2026 (prior entries archived).

CMS-1500Claim form governed by this policy

MultipleCode groups referenced (examples)

All productsScope breadth

Who May Report Nonphysician-Specific CPT/HCPCS Codes

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Who may report nonphysician-specific CPT codes

Determines when codes intended for nonphysician health care professionals are reimbursable.

ALL of the following

If the provider reporting the nonphysician-specific CPT/HCPCS code is a qualified nonphysician health care professional, the code is appropriate.
If the provider is a Physician (MD or DO), UnitedHealthcare will not reimburse nonphysician-specific codes for services provided by that Physician; Physicians should report the service using appropriate Evaluation and Management (E/M) or other physician-level codes.

Code Groups and Coverage Status

Health and Behavior Assessment/Intervention (nonphysician codes)CPTNot Covered

96156	Health and behavior assessment/intervention — nonphysician use only (per policy)
96158	Health and behavior intervention, individual, nonphysician
96159	Health and behavior intervention, multiple
96164	Health and behavior assessment, family
96165	Health and behavior intervention, family
96167	Health and behavior assessment/intervention, group
96168	Health and behavior intervention, group
96170	Health and behavior assessment/intervention, team
96171	Health and behavior intervention, team

Medical nutrition therapy and related nonphysician codesCPT|HCPCSCovered

97802	Medical nutrition therapy; initial assessment and intervention, individual
97803	Medical nutrition therapy; re-assessment and intervention
97804	Medical nutrition therapy; group
98960	Education and training for patient self-management by qualified nonphysician
98961	Education and training for patient self-management, each additional 30 minutes
98962	Education and training for patient self-management, group
G0270	Physician or other qualified health care professional providing medical nutrition therapy; initial assessment
G0271	Medical nutrition therapy; subsequent or additional sessions

Other nonphysician encounter codes (historical/misc)CPT|HCPCS|Other

96041	Listed in code mapping section (source document mapping entries)
99605	Medication therapy management; initial 15 minutes — pharmacist
99606	Medication therapy management; each additional 15 minutes — pharmacist
99607	Medication therapy management; group
G2251	HCPCS listed in code mapping section
G0323	HCPCS listed in code mapping section

Required Billing and Documentation Actions

Billing Rule

Reporting by provider type

Do not report nonphysician-specific CPT/HCPCS codes when the performing provider is a Physician (MD or DO); Physicians must report equivalent services using appropriate Evaluation and Management (E/M) or other physician-level codes.

96156
96158
96159
96164
96165
96167
96168
96170
96171
97802
97803
97804
98960
98961
98962
G0270
G0271

Documentation Required

Accurate claim submission responsibility

Submit accurate claims using codes that correctly describe the services provided; UnitedHealthcare may use reasonable discretion in interpreting and applying this policy and may be constrained by claims processing systems.

Policy may not be implemented exactly the same way on different electronic claims processing systems due to programming or other constraints.

Policy Scope and Background

This reimbursement policy governs correct coding methodology and payment for services billed on the CMS-1500 (or electronic equivalent) with emphasis on the use of CPT and HCPCS codes by nonphysician health care professionals versus Physicians. It applies to all products and to all network and non‑network Physicians and other qualified health care professionals submitting CMS‑1500 claims to UnitedHealthcare, and is intended to ensure claims are submitted using the code or codes that correctly describe the health care services provided.

UnitedHealthcare follows AMA CPT guidance that some codes are intended specifically for qualified nonphysician providers (for example, the health and behavior series and certain medical nutrition therapy and patient self‑management education codes). In accordance with those guidelines, UnitedHealthcare will not reimburse nonphysician-specific CPT/HCPCS codes when they are reported by a Physician (MD or DO); Physicians should instead report equivalent services using appropriate Evaluation and Management or other physician‑level codes. UnitedHealthcare may exercise reasonable discretion in interpreting and applying this policy and may be constrained by claims processing systems.

Resources referenced for code definitions and code set guidance include the American Medical Association, Current Procedural Terminology (CPT®) and the CMS HCPCS code sets. History notes: the policy version changed effective 1/1/2026 and the code list was updated effective 1/1/2025.

Policy Revision History

2026-01-01Policy version changeLatest

Policy version change effective 1/1/2026; prior entries through 1/1/2024 were archived.

2025-01-01Code list updated

Policy version change with code list updated (code section updated) and history entries prior to 1/1/2023 archived.

2013-09-14Policy implemented

Policy implemented by UnitedHealthcare Employer & Individual.

2013-02-13Policy approval

Policy approved by the National Reimbursement Forum.

Quick Reference

Policy Metadata

Policy Number2026R5006A

Effective Date2026-01-01

Next Review Date

SubjectCMS-1500 coding and reimbursement for nonphysician health care professional services

StatusCURRENT

Scope SummaryReimbursement policy governing correct coding methodology and payment for services billed on the CMS-1500 (and electronic equivalent) with emphasis on use of CPT/HCPCS codes by nonphysician health care professionals vs physicians; applies to all products and providers submitting CMS-1500 claims to UnitedHealthcare.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS-1500 coding and reimbursement for nonphysician health care professional services

Policy CodePolicy 2026R5006A

Change TypeCode list and version updates

Effective DateJan 1, 2026

Next Review Date

Key ActionDo not report nonphysician-specific CPT/HCPCS codes when the performing provider is a Physician; Physicians must report equivalent services using appropriate E/M or physician-level codes.

SourceLink

On This Page

OpenPayer

CMS-1500 coding and reimbursement for nonphysician health care professional services

Who May Report Nonphysician-Specific CPT/HCPCS Codes

Code Groups and Coverage Status

Required Billing and Documentation Actions

Policy Scope and Background

Defined Terms

Policy Revision History

Quick Reference