CurrentColorado Rocky Mountain Health PlansPolicy 2025R9046A

CMS 1500 reimbursement for perfusionist/nonphysician inpatient services

Policy governing reimbursement for services billed on the CMS 1500 form to UnitedHealthcare Medicare Advantage plans, specifying that certain nonphysician/perfusionist services reported on CMS 1500 are not separately reimbursable for inpatients. Affects network physicians and other qualified health care professionals furnishing services to Medicare Advantage enrollees.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 reimbursement for perfusionist/nonphysician inpatient services

Policy CodePolicy 2025R9046A

Change TypeAdministrative updates (version history)

Effective Date

Next Review Date

Key ActionDo not bill perfusionist/nonphysician inpatient services (e.g., 99190, 99191, 99192, 86891, P9022) separately on CMS 1500; these are included in facility payment.

SourceLink

POLICY UPDATE CHANGES

Application Section: Updated.

Policy Version Change History entries updated on 5/1/2025 and earlier dates archived.

3Perfusionist inpatient-only codes

2Associated additional codes

1Form type (CMS 1500)

All MA productsApplicability

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Inpatient Nonphysician Service Reimbursement Rules

Inpatient nonphysician service reimbursement rules

UnitedHealthcare Medicare Advantage will not allow separate reimbursement for specified nonphysician/perfusionist services furnished to inpatients; these services are considered included in hospital/facility payments under the Prospective Payment System (PPS).

ALL of the following

Inpatient nonphysician services must be furnished directly by the hospital or billed through the hospital under arrangements.
Services reported on the CMS-1500 form by a physician or other qualified health care professional are not separately reimbursable when furnished to inpatients because costs for nonphysician services are included in the facility payment under PPS.
Specified perfusionist and associated codes (not separately reimbursable for inpatient services)
- CPT codes 99190, 99191, 99192 (perfusionist services) are considered inpatient-only and are not separately payable when billed on CMS-1500 for inpatient services.
- Codes billed in conjunction with perfusionist services (86891, P9022) are also not separately reimbursable for inpatient services.

Perfusionist and Billing Codes

Perfusionist and associated codesCPTNot Covered

99190	Perfusionist services
99191	Perfusionist services
99192	Perfusionist services
86891	Services billed in conjunction with perfusionist services
P9022	Services billed in conjunction with perfusionist services

Place of Service Restriction — Inpatient (POS 21)

Place of service restrictionNot separately reimbursable when provided to inpatients (place of service inpatient/21); nonphysician services are deemed included in the facility payment and not separately reimbursable when reported on a CMS-1500 claim form.

Affected codesPerfusionist services CPT 99190, 99191, 99192 and associated codes 86891, P9022 are not separately reimbursable for inpatient services.

Billing instructionDo not bill these nonphysician/perfusionist services separately on the CMS‑1500 for inpatient (POS 21); services must be furnished by or billed through the hospital under arrangements.

Claims Submission & Billing Guidance

Documentation Required

Claims submission guidance

Submit accurate claims on the CMS 1500 (or electronic equivalent) form; ensure claim coding correctly describes the services provided because this policy applies to all services billed on CMS 1500 for UnitedHealthcare Medicare Advantage plans. The policy does not include prior authorization notations—it is focused on accurate claim submission and coding methodology consistent with CMS and CPT guidance.

Use CMS 1500 or its electronic equivalent for claim submission.
Ensure codes billed accurately describe the services provided.
This policy governs reimbursement and does not document prior authorization requirements.

Billing Rule

Inpatient-only billing restriction — do not bill separately

Key Terms

Prospective Payment System (PPS) — Definition

DefinitionA Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount for services.

ScopePPS payment amounts are derived from classification systems (for example, diagnosis-related groups for inpatient hospital services).

ApplicationCMS uses separate PPSs for acute inpatient hospitals, hospital outpatient, home health, hospice, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities.

Physician / Practitioner — Definition

Physician definitionDoctors of medicine (MD) and osteopathy (DO); doctors of dental surgery or dental medicine; doctors of podiatric medicine; and doctors of optometry authorized by state law.

Policy Version and Changes

2025-05-01policy_version_changeLatest

Policy Version Change History updated; entries prior to 2023 archived.

2024-05-01application_section_update

Application section updated.

2023-05-01policy_version_change

Logo updated; History section entries prior to 2021 archived.