CurrentUnitedHealthcarePolicy 2026R0056A

CMS 1500 Reimbursement / Rebundling (Bundling) Policy

Policy governing reimbursement determinations for services billed on the CMS-1500 (and electronic equivalent) by the same individual provider, addressing rebundling/unbundling, incidental, mutually exclusive, transferred services and recognized modifiers for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Reimbursement / Rebundling (Bundling) Policy

Policy CodePolicy 2026R0056A

Change TypeTemplate clarificationQ&A revisions

Effective Date

Next Review Date

Key ActionUse appropriate modifiers and consult the UnitedHealthcare Claims Tool to determine bundling before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Q&A #13 revised on 4/1/2025 and 1/1/2025; Q&A #13 added on 9/1/2024.

Template updated 4/1/2024 to indicate the policy applies to all UnitedHealthcare Commercial and Individual Exchange benefit plans.

CMS-1500Form this policy applies to

All UH Commercial & ExchangeApplies to

QuarterlyRebundling edits update frequency

25,59,XE,XP,XS,XUModifiers recognized

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CPT, CMS NCCI, CMS Policy

Coverage Criteria for Separate Reimbursement

UnitedHealthcare will not reimburse services determined to be incidental, mutually exclusive, transferred, or unbundled to a more comprehensive service unless reported with an appropriate modifier and supported by coding guidance. Modifiers do not automatically bypass bundling edits and must be used in accordance with AMA/CMS guidance.

Evaluate codes billed by the Same Individual Physician or Other Qualified Health Care Professional (same individual reporting the same Federal Tax Identification number) for the same member on the same date of service for potential bundling/rebundling.

Determine whether codes meet definitions for Incidental, Mutually Exclusive, Transferred, or Unbundled services per policy sources (CPT, CMS NCCI, CMS policy, specialty societies).

ALL of the following

Recognized modifiers include (but are not limited to) 25, 59, XE, XP, XS, XU and others listed in the policy.
Modifiers do not automatically bypass edits; use Claims Tool to confirm bundling prior to claim submission.

Do not separately reimburse when any of the following apply:

Services are incidental to a primary procedure (Incidental Services are not separately reimbursable).
Services are Mutually Exclusive (cannot reasonably be done in the same session or represent two methods of the same service); when submitted together, only one service is allowed.
Services are Unbundled (multiple codes fragment a single comprehensive service) and the comprehensive code describes the component services.

Representative examples not separately reimbursed:

J1642 (Heparin lock flush) — included in practice expense; not separately reimbursed consistent with CMS.
99173 (vision screening) — not separately reimbursed with an E/M service.
A4550 (surgical trays) — supply included in practice expense; not separately reimbursed when submitted with an E/M service or procedure.
58700 and 58940 — not separately reportable when submitted with 58150 (total abdominal hysterectomy) because 58150 includes these services.
57410 and 92502 (examinations under general anesthesia) — not separately reimbursable when performed with a related surgical procedure in the same anatomical area.
44950 and 44970 (appendectomy/laparoscopic appendectomy) — included in more extensive intra‑abdominal procedures; use 44979 when appropriate during another major procedure; no modifiers override these edits.

Operational guidance: Providers should consult the UnitedHealthcare Claims Tool (www.uhcprovider.com) to determine how Rebundling edits apply to code combinations prior to claim submission; rebundling edits are updated quarterly.

Representative Codes, Modifiers, and Provider/Claim Requirements

Representative codes and payer stancemixedCovered

J1642	Heparin sodium (Heparin Lock Flush) — not separately reimbursed per CMS (included in practice expense)
99173	Vision screening — not separately reimbursed with E/M (included)
58150	Total abdominal hysterectomy — comprehensive; includes 58700 and 58940
58700	Salpingectomy — not separately reportable with 58150
58940	Oophorectomy — not separately reportable with 58150
57410	Pelvic exam under anesthesia — not separately reimbursable when performed with related surgical procedure in same anatomic area
92502	Otolaryngologic examination under general anesthesia — not separately reimbursable when performed with related surgical procedure in same anatomic area
A4550	Surgical trays — included in practice expense; not separately reimbursed
99211	E/M code 99211 — not separately reimbursed when reported with hydration/IV infusion/injection services
G0442-G0447	Screening codes — considered included in an E/M service

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Same Individual Physician or QHP requirement

RequirementCodes billed by the same individual provider reporting the same Federal Tax Identification number on the same date of service are evaluated for bundling/rebundling.

Evaluation ScopeEvaluation applies to services billed on the CMS-1500 (and electronic equivalent) by the same rendering individual and same TIN for the same member and date of service.

Action for ProvidersUse the UnitedHealthcare Claims Tool to determine how rebundling edits apply prior to claim submission.

PurposeEnsure CPT/HCPCS codes most comprehensively describing services are reported and prevent separate reimbursement for services that are incidental, mutually exclusive, transferred or unbundled.

Billing Guidance and Claim Preparation

Prior Authorization

Prior authorization / Claim preparation guidance — use appropriate modifiers and consult Claims Tool

Use appropriate, guideline-supported modifiers when reporting services that may be considered bundled; consult the UnitedHealthcare Claims Tool on uhcprovider.com to determine how rebundling/bundling edits apply prior to claim submission. Modifiers do not automatically bypass edits and must be used according to correct coding guidance.

Check the Claims Tool (www.uhcprovider.com) to determine bundling before submitting the claim.
Only use modifiers (e.g., 59, XE, XS, XU, 25) when supported by AMA/CMS/ CPT/HCPCS coding guidance; informational modifiers (e.g., LT) do not override bundling.
Modifiers do not automatically bypass edits — documentation must support modifier use per coding guidelines.

Definitions — Unbundling, Incidental, Mutually Exclusive, Rebundling, Same Individual Physician/QHP

Unbundling — definition and examples

DefinitionUnbundling: Submitting multiple procedure codes for a group of procedures that are described by a single comprehensive code (fragmenting one service into component parts).

ExampleFragmenting a comprehensive surgical service into component parts and coding each component separately instead of using the single comprehensive code.

ImplicationServices identified as unbundled will not be reimbursed separately unless appropriate, guideline-supported modifier documentation justifies separate payment.

Incidental Services — definition and implications

DefinitionIncidental Services: Procedures performed along with the primary procedure that are not essential to complete the procedure and typically do not significantly impact the work and time of the primary procedure.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Reimbursement / Rebundling (Bundling) Policy

Policy CodePolicy 2026R0056A

Change TypeTemplate clarificationQ&A revisions

Effective Date

Next Review Date

Key ActionUse appropriate modifiers and consult the UnitedHealthcare Claims Tool to determine bundling before submitting claims.

SourceLink

On This Page

G0442–G0447 and G0473 (screening codes) — considered included in an E/M service.

99211 — not separately reimbursed when reported with hydration, therapeutic, prophylactic, or diagnostic IV infusion or injection services; 99211 may be reported by QHPs other than physicians and therefore is not allowed separately with these services.

G2211 and G0545 (visit complexity add‑ons) — not paid separately when billed with an E/M service by the same provider on the same date of service.

Reimbursement ImplicationIncidental procedures are not separately reimbursable when performed with the primary procedure.

AssessmentDetermination based on whether the procedure meaningfully increases work/time of the primary service per coding guidance and edit sources.

Mutually Exclusive Services — definition and examples

DefinitionMutually Exclusive Services: Coding combinations that cannot reasonably be done in the same session or represent two methods of performing the same service; when submitted together the combination is considered submitted in error and only one service is allowed.

CriteriaDetermination may use criteria such as services not reasonably doable in same session or coding that represents alternate methods of the same service.

ResultWhen mutually exclusive, edits disallow separate reimbursement for both services and only one will be allowed.

Rebundling — definition and description

DefinitionRebundling: Identifying and combining specific coding relationships into the most comprehensive and/or appropriate procedure code.

When It OccursRebundling may occur when services are considered incidental, mutually exclusive, transferred, or unbundled.

PurposeEnsure that coding reflects the most comprehensive code for the services performed and prevent separate reimbursement for component or overlapping codes.

Same Individual Physician or Other QHP — definition clarifying same rendering individual and same TIN

DefinitionSame Individual Physician or Other QHP: The same individual rendering health care services reporting the same Federal Tax Identification number.

RelevanceUsed to determine when codes billed together should be evaluated for bundling/rebundling on the same date of service.

Provider GuidanceProviders should confirm the rendering individual and TIN when checking bundling rules in the Claims Tool prior to claim submission.