CurrentColorado Rocky Mountain Health PlansPolicy N/A

One or More Sessions reimbursement policy (Defined Treatment Period)

Defines reimbursement rules for CPT/HCPCS codes that are payable only once during a Defined Treatment Period for UnitedHealthcare Community Plan providers submitting CMS-1500 or electronic equivalent; applies to all products and network/non-network physicians and qualified health care professionals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOne or More Sessions reimbursement policy (Defined Treatment Period)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReport appropriate modifier when submitting multiple occurrences of the same CPT/HCPCS code during the Defined Treatment Period; use anatomic modifiers (LT/RT) for laterality.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1500claim form to which this policy applies

Oncecodes reimbursed during Defined Treatment Period (only once unless modifier)

10 or 90 daysDefined Treatment Period lengths referenced

9 modifiers listedrecognized modifiers under this policy (examples)

Indiana

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.

One or More Sessions — Reimbursement Criteria

Coverage criteria for One or More Sessions

Reimbursement criteria for services performed in one or more sessions within a Defined Treatment Period:

A CPT/HCPCS code described as treatment at one or more sessions will be reimbursed only once during its Defined Treatment Period unless an appropriate modifier is reported.

The Defined Treatment Period mirrors the National Physician Fee Schedule (NPFS) global fee period; multiple submissions of the same CPT/HCPCS code by the Same Physician or Other Health Care Professional for the same patient during that period will be denied as part of the global service unless an appropriate modifier is reported.

For purposes of this policy, 'Same Physician or Other Health Care Professional' means physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification Number (TIN).

Appropriate modifiers should be reported to indicate altered, staged, distinct, or separate-anatomic services. Designated modifiers recognized under this policy include: LT, RT, 50, 52, 53, 54, 55, 56, and 79. Anatomic modifiers (LT/RT) are required to report procedures on different eyes for consideration of reimbursement.

State-specific and situational rules: Indiana does not recognize modifier 56; follow state regulations where noted.

Timing and window

The Defined Treatment Period begins the day of the procedure and includes the specified NPFS global period days before and after the procedure (examples used in this policy include 10-day and 90-day periods).
Example: For a code with a 90-day Defined Treatment Period performed on 10/1, services from 7/3 through 12/30 are considered within the treatment period and subject to the single-reimbursement rule.

Interactions with other providers

If a subsequent procedure is performed by the same specialty provider reporting under the same TIN within the Defined Treatment Period, it will be denied as part of the global service unless appropriately modified.
If a different surgeon of a different specialty or a provider reporting under a different TIN performs subsequent surgery within the Defined Treatment Period, the subsequent surgery may be considered for reimbursement.

Services addressed by this One or More Sessions policy may also be subject to global surgical package guidelines; refer to the Global Days policy for additional information.

When a first procedure is reported with modifiers that indicate reduced or discontinued services (for example, 52 or 53) and a subsequent unmodified global code is submitted within the same Defined Treatment Period, reimbursement will be adjusted according to the modifier reporting and global period rules.

Codes, Defined Treatment Periods, and Status

One or More Sessions codes (partial)CPTCovered

61796	Treatment/Monitoring Period = 90
61798	Treatment/Monitoring Period = 90
62263	Treatment/Monitoring Period = 10
62264	Treatment/Monitoring Period = 10
63620	Treatment/Monitoring Period = 90
66762	Treatment/Monitoring Period = 90
66821	Treatment/Monitoring Period = 90

Additional ophthalmology codes with 90-day periodCPTCovered

66840	Treatment/Monitoring Period = 90
67031	Treatment/Monitoring Period = 90
67208	Treatment/Monitoring Period = 90
67210	Treatment/Monitoring Period = 90
67218	Treatment/Monitoring Period = 90
67220	Treatment/Monitoring Period = 90
67229	Treatment/Monitoring Period = 90

inv-04: Defined Treatment Period window

Defined Treatment Period — startBegins the day of the procedure (the first day of the Defined Treatment Period)

Defined Treatment Period — window examplesIncludes the specified global period days before and after the procedure (examples referenced: 10-day and 90-day periods)

Defined Treatment Period — NPFS alignmentMirrors the National Physician Fee Schedule (NPFS) global fee period assigned to the code

Defined Treatment Period — inclusion of encountersMultiple patient encounters that fall within the window are considered part of the same Defined Treatment Period for that code

Submission, Modifier, and Billing Requirements

Documentation Required

Modifier and submission requirements

Report an appropriate modifier when submitting multiple occurrences of the same CPT/HCPCS code during the Defined Treatment Period; use anatomic modifiers (LT/RT) to indicate procedures on different eyes so the subsequent procedure may be considered for reimbursement. UnitedHealthcare Community Plan recognizes the following designated modifiers when appropriately reported: LT, RT, 50, 52, 53, 54, 55, 56, 79. Note state exception: Indiana does not recognize modifier 56.

If the same physician submits multiple occurrences of the same code during the Defined Treatment Period, claims will be denied as part of the global service unless an appropriate modifier is reported. [[source cited above]]
When surgeries are performed on different eyes within the Defined Treatment Period, anatomic modifiers LT and/or RT must be used for consideration of reimbursement. [[source cited above]]
If the first procedure was reported with modifier 52 or 53 and a second unmodified global code is submitted within the same Defined Treatment Period, partial reimbursement will be adjusted and the global code reimbursed. [[source cited above]]
Per state regulations, Indiana does not recognize modifier 56. [[source cited above]]

Key Definitions and Scope Terms

inv-06: Physicians/other health care professionals of the same group and same specialty reporting the same Federal Tax Identification Number (TIN)

Definition — Same Physician or Other Health Care ProfessionalPhysicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification Number (TIN)

Effect on subsequent claimsMultiple submissions of the same CPT/HCPCS code by the Same Physician or Other Health Care Professional for the same patient during the Defined Treatment Period will be denied as part of the global service unless an appropriate modifier is reported.

Different specialty or TINIf a different specialty or different TIN performs subsequent surgery within the Defined Treatment Period, subsequent surgeries may be considered for reimbursement.

inv-07: The timeframe corresponding to the NPFS global fee period assigned to a code (begins day of procedure and includes the specified number of days before and after)

Defined Treatment Period timeframeBegins the day of the procedure and includes the specified number of days before and after the procedure as assigned by the NPFS global fee period (examples: 10 days or 90 days)