CurrentColorado Rocky Mountain Health PlansPolicy N/A

Status M and Q code reimbursement and modifier denials

Defines UnitedHealthcare Community Plan's reimbursement stance for CMS NPFS status M and Q codes and certain modifiers for Medicaid products billed on CMS-1500/UB04; applies to network and non-network physicians and other qualified health care professionals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyStatus M and Q code reimbursement and modifier denials

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDeny codes with CMS NPFS status M or Q reported on CMS-1500 and deny codes appended with specified modifiers when billed by physicians or other qualified health care professionals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

M and QCMS NPFS status codes denied when reported on CMS-1500

MultipleModifiers that will trigger denials

ListedState-specific exceptions

CMS-1500Forms covered

Coverage and Denial Criteria

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Denial and exception criteria

UnitedHealthcare Community Plan will deny billing of codes designated as status M or Q on the CMS NPFS when reported on a CMS-1500 form; certain modifiers appended to codes reported by physicians or other qualified health care professionals will also be denied. State-specific exceptions apply as noted.

Deny reimbursement for codes with NPFS status M or Q when reported on a CMS-1500 form.

Status M = Measurement codes used for reporting purposes only; Status Q = Therapy functional information codes used for required reporting purposes only.

Deny codes appended with specified modifiers when reported by a physician or other qualified health care professional, except where state-specific exceptions permit.

See modifier exceptions by state (e.g., Colorado excludes HCPCS codes G8431, G8510, G8511 from modifier exclusions).

State exceptions (informational)

Arizona: Arizona Medicaid is excluded from modifiers 27, 73 and 74 in the Modifier Section.
Colorado: Colorado Medicaid excludes HCPC codes G8431, G8510, and G8511.
Indiana: Indiana will allow the SL modifier to be appended to appropriate vaccine administration procedure code.
Kentucky: Kentucky Medicaid is excluded from modifier 27 in the Modifier Section.
Missouri: Based on State requirements, G8431 and G8510 are considered reimbursable.
New Jersey: New Jersey Medicaid allows reimbursement for codes G9919 and G9920 when billed with modifier 33.
New York: Based on State requirements, G8431 and G8510 are considered reimbursable.
Ohio: Based on Medicaid requirements, M and Q codes are allowed based on Ohio MMP reporting and billing requirements.
Tennessee: Tennessee Medicaid to allow 0500F to be reimbursed in addition to 99202-99205 & 99211-99215.
Texas: Texas Medicaid will allow physician reimbursement for G8431 or G8510.

Refer to the policy attachments for the complete list of Status M and Status Q codes subject to denial.

Codes and Modifiers Not Payable

CMS NPFS status codes not payablemixedNot Covered

Status M	Measurement codes — for reporting purposes only; will be denied when reported on CMS-1500
Status Q	Therapy functional information codes — for required reporting purposes only; will be denied when reported on CMS-1500

Modifiers denied when billed by physicians/qualified professionalsModifierNot Covered

Modifier 73	Denial when appended by physician/qualified professional
Modifier 74	Denial when appended by physician/qualified professional
Modifier PO	Denial when appended by physician/qualified professional
Modifier SL	Denied except where state exception allows (vaccines in some states)

Billing Rules and Provider Guidance

Denial Risk

Denial Rules — Status M/Q Codes and Specified Modifiers

Codes with CMS NPFS Relative Value File status M or Q are for reporting purposes only and will be denied when submitted on a CMS-1500 by a physician or other qualified health care professional. Additionally, claims for services reported with specified ASC/outpatient-related or agency-funded modifiers will be denied when billed by physicians or other qualified health care professionals.

Denial triggers: any code with CMS NPFS status M or Q reported on a CMS-1500 form (reporting-only codes).
Denied modifiers (ASC / outpatient-designated when billed by physicians or other qualified health care professionals): 73, 74, PO.
Denied modifiers (services funded by county/state/federal agency — denied when reported by physicians or other qualified health care professionals; ambulance transport exception noted for SE): SL, HV, HZ, H9, HX, TR, HU, HY, (and other related agency-funded modifiers).
Ambulance transport exception: modifier SE is used to report origin/destination and is not part of these denials for ambulance transport providers.

Definitions and Reporting-Only Codes

Status M — Measurement codes (not separately payable)

DefinitionStatus M — Measurement codes used for reporting purposes only and not separately payable.

Policy actionCodes with NPFS Status M reported on a CMS-1500 will be denied as they are designated 'for reporting purposes only.'

ScopeApplies to services billed on a CMS-1500 form (or electronic equivalent) for Medicaid products.

ReferenceSee NPFS Relative Value File public use file and the policy Attachment for the complete list of Status M codes.

Status Q — Therapy functional information codes (not separately payable)

DefinitionStatus Q — Therapy functional information codes used for required reporting purposes only and not separately payable.

Policy actionCodes with NPFS Status Q reported on a CMS-1500 will be denied as they are designated 'for reporting purposes only.'