CurrentUnitedHealthcarePolicy 2025R0124B

CMS 1500 Reimbursement Policy

Defines UnitedHealthcare's reimbursement and denial rules for services billed on CMS-1500 forms (and specified UB04) for Commercial and Individual Exchange plans, including status indicator and modifier-based denials.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Reimbursement Policy

Policy CodePolicy 2025R0124B

Change TypeOperational and template updates

Effective Date

Next Review Date

Key ActionDo not bill Status E, X, or M-designated codes on CMS-1500; such codes will be denied.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Guidelines: Removed Q status code reference and updated the Status M Codes list.

Attachments: Status M and Q lists updated on earlier revisions.

Template transferred to a shared policy template applying to both Commercial and Individual Exchange plans.

Status E & Xcode groups denied when billed on CMS-1500

Status Mcodes for reporting only; denied when billed on CMS-1500

CMS-1500/UB04Applicable settings

CPT/CMS refsIncluded resources

Denial and Billing Criteria for CMS-1500

Denial criteria for CMS-1500 billed codes and modifiers

UnitedHealthcare will deny the following when reported on a CMS-1500 form or electronic equivalent:

Codes with Status E: items/services excluded from fee schedule payment by regulation; no RVUs shown; not payable under the physician fee schedule.

Codes with Status X: items/services not in the statutory definition of 'physician services' for fee schedule payment; no RVUs shown; not payable under the physician fee schedule.

Codes with Status M: measurement/reporting codes designated for reporting only; denied when billed on a CMS-1500 form.

Specified modifiers and modifier groups when appended by physicians or other health care professionals will result in denial per policy (see policy modifier guidance and attachments for details).

Status Indicator Codes and Payment Eligibility

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Reimbursement Policy

Policy CodePolicy 2025R0124B

Change TypeOperational and template updates

Effective Date

Next Review Date

Key ActionDo not bill Status E, X, or M-designated codes on CMS-1500; such codes will be denied.

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.

Status EmixedNot Covered

Status E

Items/services excluded from fee schedule payment by regulation; no RVUs; denied under physician fee schedule.

Status XmixedNot Covered

Status X

Items/services not in statutory definition of physician services for fee schedule payment; no RVUs; denied.

Status MmixedNot Covered

Status M

Measurement/reporting codes designated for reporting only; denied when billed on CMS-1500.

Payment eligibility

Status EItems/services excluded from the fee schedule by regulation; no RVUs shown and no payment may be made under the physician fee schedule.

Status XItems/services not in the statutory definition of ‘physician services’ for fee schedule payment; no RVUs or payment amounts shown and not payable under the physician fee schedule.

Status MMeasurement/reporting codes designated for reporting only; will be denied when reported on a CMS-1500 form.

Billing and Denial Actions for Providers

Denial Risk

Do not bill Status E, X, or M codes on CMS-1500; avoid specified modifiers

Do not bill Status E, Status X, or Status M-designated codes on a CMS-1500 form (or electronic equivalent); UnitedHealthcare will deny select Status E and X codes and will deny Status M codes reported on a CMS-1500 because they are excluded from fee-schedule payment or are reporting-only. Do not append the listed ASC/outpatient or externally funded modifiers when reporting services as a physician or other health care professional; codes appended with those modifiers will be denied.

Status E: codes excluded from fee-schedule payment by regulation; no RVUs; not payable under physician fee schedule. (Denied when billed on CMS-1500) [[see citation]]
Status X: codes not within statutory definition of physician services; no RVUs; not payable under physician fee schedule. (Denied when billed on CMS-1500) [[see citation]]
Status M: measurement/reporting codes designated for reporting only; denied when billed on CMS-1500.
Modifiers denied when appended by physicians or other health care professionals: 27, 73, 74, PO.
Modifiers representing services funded by government agencies (examples listed in policy) will also be denied when appended by physicians or other health care professionals.

OpenPayer

CMS 1500 Reimbursement Policy

Denial and Billing Criteria for CMS-1500

Status Indicator Codes and Payment Eligibility

Billing and Denial Actions for Providers

Key Terms