CurrentColorado Rocky Mountain Health PlansPolicy CMS1500 Policy Number 2026R0120A

Reimbursement for services billed with HCPCS modifier SU on CMS-1500 claims

Governs reimbursement for services billed with modifier SU (procedure performed in physician's office to denote use of facility/equipment) on CMS-1500 forms for UnitedHealthcare Community Plan Medicaid products and affects all network and non-network physicians and qualified health care professionals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for services billed with HCPCS modifier SU on CMS-1500 claims

Policy CodePolicy CMS1500 Policy Number 2026R0120A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDo not expect separate reimbursement for services appended with modifier SU when billed in an office place of service; modifier SU is not payable per CMS and UnitedHealthcare Community Plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form

SU not reimbursedcoverage stance

PA, TX, WAstate exceptions

Medicaidproduct applicability

Modifier SU Reimbursement Criteria

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Modifier SU reimbursement criteria

Covered when ALL of the following are met:

Modifier SU appended to services billed in an office place of service is not reimbursed because practice expense RVUs include office operating costs (rent, equipment, supplies, non-physician staff).

Charges associated with the use of modifier SU submitted by a different provider than the physician performing the office procedure will not be considered for separate reimbursement (these practice expenses are included in the physician's reimbursement).

State exceptions

Pennsylvania: SU modifier is allowed when reported with CPT code 55250 in POS 11.
Texas: SU modifier is allowed on CPT codes 86001, 86003, and 86005.
Washington: Reimburses for a facility fee when services are performed in birthing centers licensed by the Department of Health with a Core Provider Agreement; facility payments are billed with SU by the midwife who must then reimburse the birthing center. When SU is attached to the delivery code, it reports use of the provider's facility or equipment only.

UnitedHealthcare Community Plan follows CMS guidance that modifier SU is not payable when billed in an office place of service and therefore separate reimbursement should not be expected.

Modifier and Billing Coding Details

Modifier SUHCPCSNot Covered

SU	HCPCS modifier - Procedure performed in physician's office (to denote use of facility and equipment)

Provider billing rule

Billing ruleCharges for facility and equipment are included in the physician's practice expense RVU; separate facility charges appended with modifier SU are not reimbursable when billed on a CMS-1500 (office place of service).

Different-provider chargesCharges associated with the use of modifier SU submitted by a different provider than the physician performing the office procedure will not be considered for separate reimbursement.

State exceptionsCertain state-specific exceptions may allow SU reimbursement (examples: Pennsylvania for CPT 55250 in POS 11; Texas for CPT 86001, 86003, 86005; Washington for licensed birthing centers meeting criteria).

Provider Billing and Reimbursement Actions

Prior Authorization

Prior authorization / reimbursement: Modifier SU not reimbursed in office POS

Do not expect separate reimbursement for services billed with modifier SU when the service is provided in an office place of service; UnitedHealthcare Community Plan follows CMS guidance that practice expense RVUs include office operating costs, so SU is not payable. Specific state exceptions may apply (examples: Pennsylvania for CPT 55250 in POS 11; Texas for CPTs 86001, 86003, 86005; Washington for licensed birthing centers meeting criteria).

Charges associated with modifier SU submitted by a different provider than the physician performing the office procedure will not be considered for separate reimbursement.
Refer to state-specific rules for allowable SU reimbursement in PA, TX, and WA as noted in the policy.

Key Definitions

Relative Value Units (RVUs)

Relative Value Unit (RVU) definitionThe assigned unit value of a particular CPT or HCPCS code; the associated RVU is either the CMS NPFS Non‑Facility Total value or Facility Total value.

Practice expense RVUCMS practice expense RVUs include office operating costs such as rent, equipment, supplies and non‑physician staff costs.

Relevance to reimbursementBecause practice expense RVUs include office facility and equipment costs, separate reimbursement for modifier SU in an office POS is not allowed by UnitedHealthcare Community Plan per CMS guidance.

Modifier SU (HCPCS)

Modifier SU meaningHCPCS modifier indicating a procedure performed in the physician's office to denote use of facility and equipment.

CMS guidanceCMS indicates modifier SU is not payable; practice expense RVUs already include office facility/equipment costs, so SU is not separately reimbursable in an office place of service.

Policy applicationUnitedHealthcare Community Plan follows CMS and does not allow reimbursement for services appended with modifier SU on CMS‑1500 claims in office POS, except where state exceptions apply.