CurrentUnitedHealthcarePolicy N/A

CCI Editing and Related Reimbursement Policy Updates

This document governs UnitedHealthcare Community Plan reimbursement policy updates (effective Sept 1, 2025) including enhanced CCI editing for shoulder arthroscopy, payment reduction for off‑campus provider‑based departments billed with modifier PO, and other code and policy revisions affecting professional and facility claims.

Policy Summary

PayerUnitedHealthcare

PolicyCCI Editing and Related Reimbursement Policy Updates

Policy CodePolicy N/A

Change TypeMultiple additions and revisions (CCI edits, PO payment reduction, MPPR, anatomical modifier rules)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionWhen billing G0463 with modifier PO expect reimbursement at 40% of allowable and confirm facility type exclusions before billing.

SourceLink

POLICY UPDATE CHANGES

UnitedHealthcare will align with CMS to deny separate reimbursement for two shoulder arthroscopic procedures performed on the same shoulder (CPT codes 29805-29828) even if an NCCI PTP modifier is appended.

A new Payment Reduction of Off‑Campus Provider‑Based Departments policy will apply a 60% reduction (payment at 40% of allowable) when HCPCS code G0463 is billed with modifier PO for applicable off‑campus departments.

Home Health Services policy added aligning with CMS: home health billed in place of service 12 will not be reimbursed if dates overlap with an inpatient stay (excluding admission and discharge dates).

Anatomical Modifier Requirement policy enhanced to require appropriate laterality/anatomical modifiers for surgical procedures with CMS bilateral status indicator 1 or claim lines will be denied.

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging policy enhanced to apply MPPR reductions to certain ultrasound CPT codes (50% TC and 5% PC for secondary/subsequent) consistent with similar MPPR status indicator codes.

Sept 1, 2025primary effective date for multiple policy changes

G0463 → 40%reimbursement when billed with modifier PO

29805-29828codes affected by enhanced CCI PTP edit for same‑shoulder arthroscopy

50% TC / 5% PCMPPR reduction applied to specified ultrasound secondary/subsequent procedures

Coverage and Edit Criteria

CCI Editing — Coverage Criteria

Covered when ALL of the following apply:

ALL of the following

Effective for dates of service on or after 2025-09-01 UnitedHealthcare aligns with the CMS National Correct Coding Initiative (NCCI) for Procedure-to-Procedure (PTP) edits involving shoulder arthroscopy procedures.
When two shoulder arthroscopy CPT codes describing procedures performed on the same shoulder are submitted together and form an NCCI PTP edit code pair (e.g., CPT codes in the range 29805-29828), the pair will not be considered for separate reimbursement regardless of modifier use, including modifier 59 or other NCCI PTP-associated modifiers.
PTP edit code pairs will be considered for separate reimbursement when the procedures are performed on opposite shoulders (appropriate laterality modifiers must be used) and when appended with an appropriate NCCI PTP-associated modifier that supports separate payment.

Policy Summary

PayerUnitedHealthcare

PolicyCCI Editing and Related Reimbursement Policy Updates

Policy CodePolicy N/A

Change TypeMultiple additions and revisions (CCI edits, PO payment reduction, MPPR, anatomical modifier rules)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionWhen billing G0463 with modifier PO expect reimbursement at 40% of allowable and confirm facility type exclusions before billing.

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 PO — Coverage Criteria

Covered when ALL of the following apply:

ALL of the following

Effective for dates of service on or after 2025-09-01 UnitedHealthcare will apply the Payment Reduction of Off‑Campus Provider‑Based Departments billed with modifier PO consistent with CMS guidance.
When HCPCS code G0463 is reported with modifier PO for services rendered in an off‑campus provider‑based department, reimbursement will be reduced to 40% of the allowable amount (i.e., a 60% reduction applies to the remaining 60%).
The modifier PO must be reported when outpatient hospital items and services are provided in an off‑campus provider‑based department of a hospital as defined by CMS (facility located outside 250 yards but within 35 miles of the main provider or otherwise designated by CMS).
The payment reduction policy does NOT apply to services rendered in the Emergency Department, Critical Access Hospitals, Psychiatric/Rehabilitation/Long‑Term Care Hospitals or units, hospitals located in Maryland, Puerto Rico or U.S. territories, Rural Sole Community Hospitals, and Indian Health Service hospitals.
Claims billed without modifier PO where the service was provided in an off‑campus provider‑based department may be subject to review; providers should append modifier PO when appropriate and retain documentation of facility location and ownership structure to support correct billing.
Operational: apply 40% payment when G0463 + PO appropriately billed; otherwise process per standard facility reimbursement.

Code-level Guidance

Shoulder arthroscopy CCI edits and exceptionsCPTCovered

29805-29828	Shoulder arthroscopy procedures subject to NCCI PTP edit
29823	Arthroscopy, shoulder, surgical; debridement
29824	Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)
29827	Arthroscopy, shoulder, surgical; with rotator cuff repair
29828	Arthroscopy, shoulder, surgical; biceps tenodesis

Off‑campus provider‑based department payment reductionHCPCSCovered

G0463

Hospital outpatient clinic visit (G0463) — reimbursement reduced when billed with modifier PO; payment at 40% of allowable (60% reduction)

MPPR reductions for ultrasound secondary/subsequent

MPPR reductions for specified ultrasound CPTsApply 50% reduction to the technical component (TC) for secondary and subsequent ultrasound procedures provided to the same patient in the same session.

Professional component reductionApply 5% reduction to the professional component (PC) for secondary and subsequent ultrasound procedures in the same session.

Scope of applicationApplies to CPT codes with an MPPR Status Indicator of '0' to align with codes assigned status indicator '4'.

Same-session requirementReductions apply when procedures are provided to the same patient in the same session on the same date of service by the same or different physicians in the same group.

Modifier guidanceWhen appropriate, append a modifier to additional ultrasound procedures to indicate they were performed during a separate session.

What Providers Must Do / Expect

Billing Rule

CCI Editing — Shoulder Arthroscopy (Provider Impact)

Do not expect separate reimbursement for two shoulder arthroscopy procedures performed on the same shoulder; UnitedHealthcare will follow CMS NCCI edits and deny separate payment when two shoulder arthroscopy CPT codes (29805-29828 PTP pairs) describe procedures on the same shoulder, even if an NCCI PTP-associated modifier (including modifier 59) is appended.

Affected codes: CPT 29805–29828 PTP edit pairs
Exception: PTP pairs may be considered for separate reimbursement when performed on opposite shoulders or when appropriate NCCI PTP-associated modifier supports separate reporting
Three NCCI manual exceptions (Chapter IV, Section E, Arthroscopy, Subsection 7) allow separate reimbursement when extensive debridement is completed in a different area of the same shoulder for codes submitted in addition to 29823: 29824, 29827, 29828

Billing Rule

Payment Reduction — Modifier PO (Provider Impact)

Append modifier PO to HCPCS code G0463 when applicable and expect reimbursement at 40% of the allowable amount for services billed from off-campus provider-based departments; UnitedHealthcare follows CMS policy effective for dates of service on or after September 1, 2025.

Affected code: HCPCS G0463 billed with Modifier PO
Reimbursement: 40% of allowable when G0463 is appropriately reported with Modifier PO
Applicability: Services in off-campus provider-based departments (outside 250 yards but within 35 miles of main provider) and not applicable to Emergency Department services, Critical Access Hospitals, Psychiatric/Rehabilitation/Long-Term Care hospitals or units, hospitals in Maryland/Puerto Rico/U.S. territories, Rural Sole Community Hospitals, or Indian Health Service hospitals

Modifiers and Key Terms

NCCI PTP modifier

DefinitionNCCI PTP modifier: modifier(s) associated with National Correct Coding Initiative Procedure-to-Procedure (PTP) edits used to indicate separate and distinct procedures for NCCI PTP code pairs.

Operational noteFor shoulder arthroscopy CPT code pairs (29805-29828), UnitedHealthcare will not consider an NCCI PTP modifier sufficient to allow separate reimbursement when both procedures are performed on the same shoulder; exceptions per the NCCI manual (Chapter IV, Section E, Subsection 7) apply.

Opposite-shoulder handlingPTP edit code pairs will be considered for separate reimbursement when performed on opposite shoulders and appended with an appropriate NCCI PTP modifier.

Modifier PO (off‑campus provider‑based department)

DefinitionModifier PO: HCPCS modifier indicating outpatient hospital items and services provided in an off-campus provider-based department of a hospital.

Facility relationshipOff-campus provider-based departments are owned and operated by the same 'main provider' and may be on the same campus or off campus; locations outside 250 yards but within 35 miles of the main provider are considered off campus.

Payment impactWhen HCPCS G0463 is reported with modifier PO, reimbursement will be considered at 40% of the allowable amount (60% reduction), subject to applicable exclusions and effective Sept 1, 2025.

Anatomical / laterality modifier requirement

RequirementSurgical procedures assigned a CMS bilateral status indicator of 1 must be reported with an appropriate laterality or anatomical modifier for the claim to be considered for reimbursement.

Accepted modifier examplesExamples include: 50, LC, LD, LM, RC, RI, E1–E4, FA, F1–F9, LT, RT, TA, T1–T9.

Consequence of omissionClaim lines not reported with the appropriate laterality or anatomical modifier will be denied.