CurrentColorado Rocky Mountain Health PlansPolicy CMS 1500

Reimbursement Policy — CMS 1500

Governs reimbursement of timed Physical Medicine and Rehabilitation CPT/HCPCS codes billed on the CMS-1500 form for UnitedHealthcare Commercial and Individual Exchange plans; excludes home and specified rehabilitation facility settings.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement Policy — CMS 1500

Policy CodePolicy CMS 1500

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf timed therapy codes exceed four per specialty per date of service, request additional reimbursement via a Reconsideration Request per the UnitedHealthcare Administrative Guide.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 4maximum timed codes reimbursed per specialty per date of service

>=8 minminimum time to bill one 15-minute unit

CMS-1500claim form

POS 12,61,62settings excluded

GN/GO/GPHCPCS modifiers

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Timed Therapy Reimbursement Criteria

Timed therapy reimbursement criteria

Reimbursement is provided for properly coded timed therapy services subject to limits and setting exclusions.

Services are timed physical medicine and rehabilitation CPT/HCPCS codes billed on the CMS-1500 form or its electronic equivalent.

Minimum time to bill one 15-minute unit is at least 8 minutes.

UnitedHealthcare reimburses up to four timed codes (equivalent to one hour) per date of service for services provided by the Same Specialty Physician or Other Qualified Health Care Professional reporting under the same Federal Tax Identification number.

If different specialty provider types in a multi-specialty group provide timed services under the same Federal Tax Identification number, reimbursement of up to four timed codes is allowed for each specialty; HCPCS modifiers GN, GO or GP may be used to distinguish specialties.

If billed timed codes exceed four per specialty per date of service, providers may request additional reimbursement via a Reconsideration Request per the UnitedHealthcare Administrative Guide; claim reconsideration may not apply in some states per state law.

CPT/HCPCS Codes and Billing Rules

Timed physical medicine and rehabilitation CPT/HCPCS codes (examples and mappings shown)mixed

97113	Therapeutic procedure; aquatic therapy with therapeutic exercises
97116	Gait training (example mapping shown in document)
97533	Sensory integrative techniques
97535	Self-care/home management training (examples shown)
97761	Prosthetic/orthotic training
97763	Orthotic/prosthetic management and training

Minimum minutes per 15‑minute unit

Minimum minutes to bill one 15-minute unitAt least 8 minutes of therapy services must be performed to meet the minimum time qualification to bill one 15‑minute unit.

Unit basisBilling is on 15‑minute timed units per CPT/HCPCS guidance.

Applies toTimed Physical Medicine and Rehabilitation CPT/HCPCS codes billed on the CMS‑1500 form or its electronic equivalent.

Maximum timed codes reimbursed per specialty per DOS

Maximum timed codes per specialty per date of serviceUp to 4 timed codes (equivalent to one hour of therapy) per date of service provided by the Same Specialty Physician or Other Qualified Health Care Professional.

Multi‑specialty groups

Reimbursement Exceptions and Reconsideration

Prior Authorization

Request Reconsideration for Excess Timed Codes

If billed timed therapy codes exceed four per specialty per date of service, UnitedHealthcare will consider additional reimbursement when a provider submits a Reconsideration Request per the UnitedHealthcare Administrative Guide; providers should follow the Administrative Guide process. Note that claim reconsideration may not apply in some states based on applicable state law.

Reconsideration Request must follow the UnitedHealthcare Administrative Guide.
Reconsideration options may be limited or unavailable in some states per state law.

Key Definitions

Same Specialty Physician or Other Qualified Health Care Professional

DefinitionSame Specialty Physician or Other Qualified Health Care Professional: providers of the same specialty within the same group reporting under the same Federal Tax Identification number.

Relevance to reimbursementReimbursement limits (up to four timed codes per date of service) apply per Same Specialty Physician or Other Qualified Health Care Professional reporting under the same Federal Tax Identification number.

Distinguishing specialtiesWhen different specialties within the same group provide services under one Tax ID, use HCPCS modifiers (GN/GO/GP) to distinguish specialty-specific timed services for reimbursement calculations.