CurrentColorado Rocky Mountain Health PlansPolicy N/A

Outpatient Facility Modifier Reimbursement (UB04) — Modifiers 52, 53, 73, 74, CT, FX, FY

Governs reimbursement and denial rules for outpatient facility (UB04) claim lines with modifiers 52, 53, 73, 74, CT, FX, and FY for UnitedHealthcare Commercial and Individual Exchange benefit plans, applying to network and non-network outpatient facility claims.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Facility Modifier Reimbursement (UB04) — Modifiers 52, 53, 73, 74, CT, FX, FY

Policy CodePolicy N/A

Change TypeClarifiedRevised

Effective DateN/A

Next Review DateOct 5, 2025

Key ActionDo not submit modifier 53 on facility (UB04) claim lines; submission with modifier 53 will cause denial.

SourceLink

POLICY UPDATE CHANGES

Updated application language to indicate the policy applies to all UnitedHealthcare Commercial and Individual Exchange benefit plans.

Clarified that modifier 53 is not appropriate on facility claim forms and will result in denial.

50%reduction for modifier 52

50%reduction for modifier 73

15%reduction for modifier CT

7% / 10%reduction for FX/FY

denial

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Facility Modifier Reimbursement (UB04) — Modifiers 52, 53, 73, 74, CT, FX, FY

Policy CodePolicy N/A

Change TypeClarifiedRevised

Effective DateN/A

Next Review DateOct 5, 2025

Key ActionDo not submit modifier 53 on facility (UB04) claim lines; submission with modifier 53 will cause denial.

SourceLink

On This Page

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.

Modifier-based Reimbursement Rules

Modifier-based reimbursement rules

When these modifiers are appended to outpatient facility UB04 claim lines, UnitedHealthcare will apply the following payment or denial rules:

ALL of the following

Modifier 52 (Reduced Services): when present on a facility claim line, the allowed amount will be reduced by 50%.
Modifier 73 (Discontinued Outpatient Hospital/ASC Procedure Prior to Anesthesia): when present on a facility claim line, the allowed amount will be reduced by 50%.
Modifier CT (CT performed on non‑NEMA XR‑29‑2013‑compliant equipment): when present on a facility claim line for CT services furnished on non‑compliant equipment, the allowed amount will be reduced by 15%.
Modifier FX (X‑ray taken using film): when present on a facility claim line, the allowed amount will be reduced by 7% for services provided prior to 2023‑01‑01 and by 10% for services on or after 2023‑01‑01.
Date threshold: 2023‑01‑01 determines whether 7% (pre‑2023) or 10% (2023 and after) applies.
Modifier FY (X‑ray taken using computed radiography/cassette‑based imaging): when present on a facility claim line, the allowed amount will be reduced by 7% for services provided prior to 2023‑01‑01 and by 10% for services on or after 2023‑01‑01.
Date threshold: 2023‑01‑01 determines whether 7% (pre‑2023) or 10% (2023 and after) applies.
Modifier 53 (Discontinued Procedures): it is not appropriate to submit modifier 53 on a facility (UB04) claim; if submitted the facility claim line will be denied and the provider may resubmit with an appropriate modifier if applicable.
Submission with modifier 53 on facility claim = denial.
Modifier 74 (Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia): informational only on facility claim lines; no reduction in reimbursement will be applied.

Modifiers and Coding Details

Modifiers affecting facility reimbursementCPTCovered

52	Reduced Services — allowed amount reduced by 50% when present on facility claim line.
53	Discontinued Procedures — not appropriate on facility claim; claim line will be denied; provider may resubmit with an appropriate modifier if applicable.
73	Discontinued Outpatient Hospital/ASC Procedure Prior to Anesthesia — allowed amount reduced by 50% when present on facility claim line.
74	Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia — informational; no reduction in reimbursement when submitted on facility claim line.
CT	Computed tomography services furnished using equipment that does not meet NEMA XR-29-2013 standard — allowed amount reduced by 15% when reported on facility claim line.
FX	X-ray taken using film — allowed amount reduced by 7% for services provided prior to January 1, 2023 and by 10% for services provided on or after January 1, 2023 when reported on facility claim line.
FY	X-ray taken using computed radiography technology/cassette-based imaging — allowed amount reduced by 7% for services provided prior to January 1, 2023 and by 10% for services provided on or after January 1, 2023 when reported on facility claim line.

FX/FY date threshold

Effective dateJanuary 1, 2023

Reduction before effective date7% reduction for FX/FY on services provided prior to January 1, 2023

Reduction on/after effective date10% reduction for FX/FY on services provided on or after January 1, 2023

Billing and Submission Guidance for Facilities

Billing Rule

Facility modifier billing guidance — do not submit modifier 53 on UB04 facility lines

Do not submit modifier 53 on outpatient facility (UB04) claim lines; submission of modifier 53 on a facility claim line will result in denial and the provider may resubmit with an appropriate modifier if applicable. Modifiers 52 and 73 will reduce the allowed amount by 50%; modifier CT reduces the allowed amount by 15% for CT services furnished on non‑NEMA XR‑29‑2013‑compliant equipment. Modifiers FX and FY reduce the allowed amount by 7% for services prior to January 1, 2023, and by 10% for services on or after January 1, 2023. Modifier 74 is informational on facility claim lines and does not reduce reimbursement.

Do not report modifier 53 on facility (UB04) claim lines — claim line will be denied; provider may resubmit with an appropriate modifier if applicable.
When modifier 52 is present on a facility claim line, reduce the allowed amount by 50%.
When modifier 73 is present on a facility claim line, reduce the allowed amount by 50%.
When modifier CT is reported for CT services on non‑NEMA XR‑29‑2013‑compliant equipment, reduce the allowed amount by 15%.
When modifier FX or FY is reported: allowed amount reduced by 7% for services before 2023‑01‑01 and by 10% for services on/after 2023‑01‑01.

Modifier Definitions

Modifier 52 — Reduced Services

Modifier52

DefinitionReduced Services

Policy effectWhen modifier 52 is present on an outpatient facility (UB04) claim line, the allowed amount will be reduced by 50%

Modifier 53 — Discontinued Procedures

Modifier53

DefinitionDiscontinued Procedures

Policy effectModifier 53 is not appropriate on facility claim forms; submission on a facility claim line will result in denial