CurrentColorado Rocky Mountain Health PlansPolicy 2026R9003A

CMS 1500 Reimbursement Policy — NPFS Status Indicators and CPT Category II

Defines UnitedHealthcare Medicare Advantage reimbursement rules for services billed on the CMS-1500 (professional) claim form, including treatment of NPFS status codes and CPT Category II codes; applies to network physicians and other qualified health care professionals participating in UnitedHealthcare Medicare Advantage plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 Reimbursement Policy — NPFS Status Indicators and CPT Category II

Policy CodePolicy 2026R9003A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must submit accurate claims and keep current with CMS and local carrier billing requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6NPFS status codes specifically addressed (B, I, M, N, P, T)

CMS-1500Claim form this policy governs

Category IICPT Category II codes treated as measurement/reporting only

NationalApplies to UnitedHealthcare Medicare Advantage plans

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Reimbursement criteria based on NPFS status indicators

Reimbursement follows CMS NPFS status indicators; codes with certain NPFS status indicators are not separately reimbursed.

Reimbursement decisions follow the NPFS status indicators; UnitedHealthcare Medicare Advantage will not separately reimburse codes assigned certain NPFS status indicators.

ALL of the following

Status indicators that prevent separate reimbursement
- Codes assigned NPFS status B (Bundled) — payment subsumed into associated services; if RVUs appear on the fee schedule, they are not used for Medicare payment.
- Codes assigned NPFS status I (Not valid for Medicare purposes) — Medicare uses another code for reporting/payment; code is not subject to the 90-day grace period.
- Codes assigned NPFS status M (Measurement) — reporting only; not separately reimbursed.
- Codes assigned NPFS status N (Non-covered) — services not covered by Medicare and not separately reimbursed.
- Codes assigned NPFS status P (Bundled/Excluded) — no RVUs/no payment amounts; no separate payment under the fee schedule.
Codes assigned NPFS status T (Injections) have limited separate payment: RVUs exist but T-coded services are payable only if no other payable physician fee schedule services are billed on the same date by the same provider; otherwise they are bundled.

Only codes with NPFS status indicators A, R, or T use RVUs for Medicare payment calculations; codes with B, I, M, N, or P do not have RVUs applied for Medicare payment.

CPT Category II codes are measurement/reporting only and are recognized as such regardless of NPFS M or I status designations; they are not used for payment.

If an item or service is covered 'incident to' a physician service and provided the same day, payment is bundled into the physician service to which it is incident; items excluded from the fee schedule (for example certain supplies) are paid under other payment provisions rather than the physician fee schedule.

If a non-payable code (status B, I, M, or P) is billed to UnitedHealthcare Medicare Advantage, the provider is liable for denial of payment; the member is held harmless and supplemental benefits may be carved out where applicable.

Code Status, RVUs, and CPT Category II

NPFS status indicatorsmixed

B	Bundled — payment subsumed into associated service; RVUs not used for Medicare payment
I	Not valid for Medicare purposes — another code used; not subject to 90-day grace period
M	Measurement — reporting only
N	Non-covered — not covered by Medicare
P	Bundled/Excluded — no RVUs/no separate payment under fee schedule
T	Injections — payable only if no other payable physician fee schedule services billed same date by same provider

CPT Category IICPT

Category II

CPT Category II tracking codes are measurement/reporting only and recognized as such regardless of M or I status indicators

inv-04: RVUs used for Medicare payment

Medicare RVU usageOnly RVUs associated with NPFS status codes A, R, or T are used for Medicare payment calculations.

Excluded status indicatorsCodes with NPFS status indicators B, I, M, N, or P are not separately reimbursed under the fee schedule.

Source for status-to-RVU ruleRule derived from NPFS Relative Value File public use file guidance referenced in the policy.

Provider Responsibilities and Billing Impacts

Denial Risk

Liability for Non‑Payable Codes

Providers are responsible for submitting accurate claims that correctly describe the services rendered. If a code billed to Colorado Rocky Mountain Health Plans (CRMH) / UnitedHealthcare Medicare Advantage is identified by CMS with a non-covered status indicator of B, I, M, or P and the code is not carved out as a supplemental benefit for the member, the provider (not the member) is liable for the denied service. Members will be held harmless when a denied code is a recognized supplemental benefit and thus carved out from the global denial.

Affected status indicators: B, I, M, P
If code is a supplemental benefit for the member it will be carved out and bypass the global denial
When non-covered codes with indicators B/I/M/P are billed and not carved out, the Provider is liable for the denied service; the member is held harmless

Note

Provider Responsibilities and Policy Updates

UnitedHealthcare Medicare Advantage policies (as applied by CRMH) may be updated at any time to reflect CMS or national coding guideline changes. Providers should keep current with CMS/local carrier updates and verify member benefit designs; consult the member’s plan documents or contact member services for coverage details. This policy does not replace contractual obligations or benefit-specific rules that may affect reimbursement.

Sign up for CMS/local carrier distributions for policy/regulatory changes
Verify whether a code is treated as a supplemental benefit for the member before billing to avoid provider liability

Key Terms

inv-07: RVU

Definition — RVURelative Value Unit (RVU): the assigned unit value of a particular CPT or HCPCS code, using the CMS NPFS Non‑Facility or Facility total value.

Definition — MPFSMedicare Physician Fee Schedule (MPFS): the comprehensive listing of fee maximums Medicare uses to reimburse physicians and other providers on a fee‑for‑service basis; Medicare bases payment on the lesser of the charge or MPFS amount.

CPT Category II treatmentCPT Category II codes are measurement/reporting only and are recognized as such regardless of NPFS M or I status indicators (used for performance measurement, not payment).

inv-08: MPFS

MPFS overviewMPFS is the fee schedule listing fee maximums used by Medicare to pay providers; the NPFS file contains RVUs, a fee schedule status indicator, and payment policy indicators for each service.

Role in reimbursementUnitedHealthcare Medicare Advantage uses the NPFS/MPFS status indicators to determine whether a code is separately payable under the fee schedule.

Attachment A referenceAttachment A of the NPFS Relative Value File provides descriptions of status code values (B, I, M, N, P, T) referenced by this policy.