Defines UnitedHealthcare reimbursement rules for supplies, drugs, DME, orthotics, prosthetics, biologicals and related HCPCS/temporary codes billed on the CMS-1500 form and the places of service where separate reimbursement is allowed or denied. Applies to UnitedHealthcare Commercial and Individual Exchange plans and to network and non-network physicians and other qualified health care professionals.
Policy Summary
PayerUnitedHealthcare
PolicyCMS-1500 Supply and HCPCS Reimbursement
Policy CodePolicy 2026R0006D
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit accurate CMS-1500 claims using appropriate HCPCS and CPT codes and do not separately bill specified supply/DME/biological/drug HCPCS codes when provided in facility places of service listed in the policy.
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Implantable marker/dosimeter rule
Coverage Criteria and Payment Determinations
Coverage Criteria and Payment Determinations
Coverage and payment determinations are based on place of service, HCPCS/CPT code, and whether the item is considered integral to a professional service or included in facility prospective payment. Separate reimbursement is allowed only when criteria below are met.
ALL of the following
If the supply, DME, orthotic, prosthetic, biological, or drug is provided in a non-facility place of service, evaluate whether the code is specifically excluded from separate reimbursement because it is considered included in the professional service or procedure (see non-facility POS list).
Separate reimbursement is allowed when ANY of the following apply:
The HCPCS code is A4648 (implantable tissue marker) or A4650 (implantable radiation dosimeter) billed on the same date of service with CPT code 19499, 32553, 49411, or 55876 when billed on a physician services claim (these codes are separately billable per CMS guidance).
If A4648 or A4650 are billed in a facility setting or without the listed CPT codes, they are not separately reimbursable.
The code is not listed on the UnitedHealthcare Supply Facility J-Code Denial Code list or Supply DME Codes in a Facility Setting and is billed in a non-facility POS where separate reimbursement is permitted.
Not separately reimbursable (facility settings / included items)
Items billed on a CMS-1500 by a physician or other qualified health care professional when provided in facility places of service POS 19, 21, 22, 23, or 24 are considered included in the facility's Prospective Payment System (PPS) and are not separately reimbursable.
See UnitedHealthcare Supply Facility J-Code Denial Code list for specific codes.
Certain DME, orthotics, prosthetics, and related supplies reported for skilled nursing facility (POS 31) and nursing facility (POS 32) are considered included in the CMS DMEPOS fee schedule payments to those facilities and are not separately reimbursable when submitted on a CMS-1500 by a physician or other qualified health care professional.
POS 31 and 32 considered SNF and nursing facility respectively.
HCPCS codes reported on the same day as an E/M service and/or procedure performed in a non-facility place of service by a physician or other qualified health care professional may be considered incorporated into the E/M or procedure code and not separately reimbursable if the supply is one of the HCPCS supply codes identified as bundled with the professional service.
Non-separately reimbursable HCPCS supply codes are those where supply cost is incorporated into the E/M/procedure reimbursement.
When determining reimbursement, always reference the applicable UnitedHealthcare code lists (Supply Facility J-Code Denial Code list; Supply DME Codes in a Facility Setting) and applicable CMS guidance to confirm whether a specific code is separately payable or bundled/included.
This policy aligns with CMS PPS methodology and CMS guidance on implantable tissue markers and dosimeters.
Implantable neurostimulator electrode (denied in facility POS and with CPT 63650 in non-facility)
63650
Percutaneous implantation of neurostimulator electrode array, epidural
Billing Responsibilities and Restrictions for Providers
Documentation Required
Submit accurate CMS-1500 claims using correct HCPCS/CPT codes
You are responsible for submission of accurate CMS-1500 claims and must report the code or codes that correctly describe the services provided. Follow CPT, CMS and other coding guidelines and submit appropriate HCPCS and CPT codes; UnitedHealthcare may exercise reasonable discretion in interpreting and applying this policy when adjudicating claims.
Billing Rule
Do not separately bill specified HCPCS when provided in facility or included in same‑day non‑facility services
Do not separately bill specified supply, DME, orthotic, prosthetic, biological or drug HCPCS codes on the CMS-1500 when services are provided in facility places of service (POS 19, 21, 22, 23, 24) or when supplies are included in same-day non-facility E/M services or procedures in the listed non‑facility POS.
Definitions and Acronyms
Prospective Payment System (PPS) definition
DefinitionProspective Payment System (PPS): a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount; facility payments are inclusive of associated supplies, DME, orthotics, prosthetics, biologicals and drugs.
ScopeCMS uses PPS to set fixed rates for various facility types (inpatient hospitals, hospital outpatient, skilled nursing facilities, etc.), which deems associated supplies and drugs included in the global facility payment.
Effect on Physician ClaimsWhen services are provided in facility places of service (POS 19, 21, 22, 23, 24), supplies, DME, orthotics, prosthetics, biologicals and drugs reported on a CMS-1500 are not separately reimbursable because they are included in the facility's PPS payment.
Alignment with UnitedHealthcare PolicyUnitedHealthcare follows CMS PPS methodology and will deny separate reimbursement for specified HCPCS supplies and related items billed on CMS-1500 from facility POS subject to PPS inclusion.
CMS-1500 definition
Policy Summary
PayerUnitedHealthcare
PolicyCMS-1500 Supply and HCPCS Reimbursement
Policy CodePolicy 2026R0006D
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit accurate CMS-1500 claims using appropriate HCPCS and CPT codes and do not separately bill specified supply/DME/biological/drug HCPCS codes when provided in facility places of service listed in the policy.
Local anesthetic agents reported using HCPCS J3490 or J3590 when billed with procedures in the range 10000-69999 in POS 11 are not separately reimbursable because the anesthetic agents are integral to the procedures.
POS 11 (Office) rule per policy.
HCPCS code L8680 (implantable neurostimulator electrode) is denied in all facility places of service as included in facility reimbursement, and is denied in non-facility places of service when reported with CPT 63650 because the electrodes are considered included in the procedure reimbursement.
HCPCS supply codes 99070 and 99072 (non-specific supply CPT codes) are not reimbursable in any setting; an appropriate Level II HCPCS code must be submitted for covered medical and surgical supplies.
Facility POS where separate reimbursement is not allowed: 19, 21, 22, 23, 24 (supplies/DME/biologicals/drugs are included in facility PPS/global payment).
Non-facility POS where certain HCPCS supplies are incorporated into E/M or procedure reimbursement and not separately reimbursable: POS 1, 3, 4, 9, 11, 13, 14, 15, 16, 17, 20, 27, 33, 49, 50, 54, 55, 57, 60, 62, 65, 71, 72, 81, 99.
Certain DME, orthotics, prosthetics and related supplies on the DMEPOS fee schedule are included in payment to skilled nursing and nursing facilities (POS 31, 32) and are not separately reimbursable on CMS-1500 submissions.
Form NameCMS-1500 (1500 Health Insurance Claim Form): the claim form or its electronic equivalent used to report professional services and supplies for reimbursement under this policy.
ApplicationThis policy applies to services reported using the CMS-1500 or its electronic equivalent for all network and non-network physicians and other qualified health care professionals, except specified exceptions (e.g., certain Home Health and DME/PO providers billing POS 12).
Use CaseUsed to submit physician/other qualified health care professional claims for supplies, DME, orthotics, prosthetics, biologicals and drugs when billing professional services.