CurrentColorado Rocky Mountain Health PlansPolicy N/A

Procedure-to-Modifier Reimbursement Policy (Modifiers — CMS/CPT/HCPCS applicability)

Governs appropriate use of CPT and HCPCS modifiers for UnitedHealthcare Community Plan Medicaid products and applies to claims billed on the CMS-1500 or electronic equivalent for network and non-network providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProcedure-to-Modifier Reimbursement Policy

Policy CodePolicy N/A

Change TypeAdministrative updates (attachments & state exceptions)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using codes and modifiers that correctly describe services; reimbursement considered only when modifiers are used appropriately.

SourceLink

POLICY UPDATE CHANGES

Attachment Section updated: Arizona Procedure to Modifier Table-Acute List and Arizona Procedure to Modifier Table-LTC

State Exceptions updated for various states (e.g., Texas, New York, Massachusetts, North Carolina, New Jersey, Arizona, Florida, Wisconsin, Tennessee, Idaho, Mississippi, Michigan, Indiana, Kentucky, Missouri, Washington, Washington DC, California removed)

List of Codes Not Allowed with Modifier JW for the state of Florida only removed

Attachment Section: Added Tennessee wheelchair base codes with modifier MS

CMS-1500 / UB04forms governed

Medicaidproduct scope

manystate exceptions present

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.

2025–2026recent version changes

Modifier Appropriateness and State Exceptions

Modifier appropriateness and state exceptions

Reimbursement is provided when the modifier is appropriate for the procedure code and consistent with coding guidance; some modifiers and code-modifier combinations are subject to state-specific exceptions or attachment tables.

Modifier is appropriate for the procedure code and used according to its descriptor and coding guidance (e.g., modifier 25 applies only to E/M services).

Modifier use aligns with third-party authoritative sources (definitive or interpretive) as applied in the Procedure to Modifier Policy.

Required therapy modifiers (HCPCS GN, GO, or GP) are reported with codes CMS designates as always therapy services for dates of service on or after July 1, 2020.

If a procedure code/modifier combination is listed on the Modifier Bypass List or other attachment tables, the attachment-specific guidance applies (including state-specific attachments).

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Any procedure code reported with an appropriate modifier may still be subject to other UnitedHealthcare Community Plan reimbursement policies; reimbursement is considered only when modifiers are used appropriately and in accordance with coding guidelines and third-party authorities.

Modifier and Code Listings

therapy modifiersHCPCSCovered

GN, GO, GP

HCPCS therapy modifiers required with codes designated by CMS as always therapy services

Modifier additionsModifierCovered

MS	Modifier MS added for Tennessee wheelchair base codes

Claim Submission, Modifier Use, and Attachments

Billing Rule

Claim submission and modifier usage — submit accurate claims using codes and modifiers that correctly describe services; reimbursement considered only when modifiers used appropriately

Submit accurate claims using codes and modifiers that correctly describe the services provided. UnitedHealthcare Community Plan will consider reimbursement for a procedure code/modifier combination only when the modifier has been used appropriately. Any procedure code reported with an appropriate modifier may still be subject to other UnitedHealthcare Community Plan reimbursement policies. Refer to the Modifier Reference Policy for additional modifier-specific guidance.

Claims must follow CPT, CMS, and other coding guidelines and industry-standard reimbursement logic.
Modifiers without third-party industry standard guidance are allowed with all CPT and HCPCS codes unless listed on the Modifier Bypass table.
A procedure code reported with an inappropriate modifier (for example, appending modifier 25 to a surgical code instead of an E/M) may not be reimbursed.

Billing Rule

Key Terms and Attachments

Modifier — definition

DefinitionA modifier is an indicator that a service or procedure was altered by a specific circumstance without changing the service definition or code; it can convey that a service was performed more than once, that unusual events occurred, or that multiple physicians/locations were involved.

PurposeProvides additional information about how a procedure was performed to support correct coding and reimbursement determinations.

ScopeApplies to CPT and HCPCS procedure codes addressed by this policy; modifiers without third‑party industry standard guidance are allowed with all CPT/HCPCS codes and are listed on the Modifier Bypass table.

Definitive/Interpretive Source

Definitive SourceA source based on very specific instructions from the given authority that provides exact codes, modifiers, or explicit coding directives.

Interpretive Source

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProcedure-to-Modifier Reimbursement Policy

Policy CodePolicy N/A

Change TypeAdministrative updates (attachments & state exceptions)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using codes and modifiers that correctly describe services; reimbursement considered only when modifiers are used appropriately.

SourceLink

On This Page

Modifier bypass and therapy modifier requirement — certain modifiers bypass this policy; some modifiers required for therapy services (GN/GO/GP)

Certain modifiers are listed on the Modifier Bypass List and are not subject to this policy. In addition, HCPCS therapy modifiers GN (speech-language pathology), GO (occupational therapy), and GP (physical therapy) are required to be reported with codes that CMS designates as always therapy services for dates of service on or after July 1, 2020. These codes are considered always therapy services regardless of who performs them and require one of the applicable therapy modifiers to indicate the service was furnished under a therapy plan of care. For a complete list of codes requiring a therapy modifier and the Modifier Bypass List, see the attachments and the Modifier Reference Policy.

Modifier Bypass List: Modifiers to which this policy does not apply are found on the Modifier Bypass table/attachment.
Therapy modifier requirement effective 7/1/2020: HCPCS modifiers GN, GO, or GP must be reported with codes CMS designates as always therapy services.
Refer to the attachment for the full list of codes requiring a therapy modifier.

Note

Attachment updates (procedure-to-modifier tables)

Attachment updates and state exception history are maintained in the Resources/History section. See attachments for state-specific procedure-to-modifier tables and updates.

Attachment Section updates include state-specific Procedure to Modifier tables (for example, Arizona Acute and LTC lists).
State Exceptions are periodically updated (examples: New Jersey, Texas, New York, Massachusetts, North Carolina, Florida).
Refer to the Resources/History for the dates and details of recent attachment and state exception updates.

A source that requires interpretation of instructions from the identified authority to correlate codes and modifiers (guidance not provided as exact code-to-modifier mappings).

Policy applicationUnitedHealthcare Community Plan bases procedure-to-modifier relationships on methodologies from third‑party authorities that may be definitive or interpretive.

Attachment Section (procedure-to-modifier tables)

Attachment Section contentsProcedure-to-Modifier tables (e.g., Arizona Procedure to Modifier Table–Acute List and Arizona Procedure to Modifier Table–LTC) used to document specific procedure-to-modifier relationships.

Recent updatesAttachment Section has been updated multiple times (examples dated 5/10/2026, 3/29/2026, 12/31/2025) to reflect changes in state or procedure-level mappings.

Archiving practiceHistory entries prior to certain dates (varies by update) have been archived when Attachment Section updates were made.

State Exceptions

DefinitionState Exceptions are state-specific deviations or additions to the main procedure-to-modifier policy that change allowable code/modifier combinations for a given state.

Examples of activityMultiple state exceptions recorded (e.g., New Jersey, Florida, Texas, New York, Massachusetts, Tennessee, Arizona); entries document updates and removals across 2023–2026.

Effect on claimsWhen a state exception applies, it overrides or modifies the main policy’s procedure-to-modifier relationships for claims billed in that state.