CurrentUnitedHealthcarePolicy CMS-1500 Policy Number 2025R0056C

Reimbursement Policy — CMS-1500 rebundling and reimbursement edits

Defines UnitedHealthcare Community Plan's rules for reimbursing CPT/HCPCS codes billed together by the same provider on the same date of service, including when services are considered incidental, mutually exclusive, transferred, or unbundled and when modifiers may permit separate payment.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy — CMS-1500 rebundling and reimbursement edits

Policy CodePolicy CMS-1500 Policy Number 2025R0056C

Change TypeNo material change

Effective Date

Next Review Date

Key ActionUse appropriate modifiers when reporting altered services; modifiers permit bypass of bundling only when used according to correct coding guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manydesignated modifiers recognized

quarterlyrebundling edits update frequency

multiplethird-party sources

state-specificstate fee-schedule exceptions

Reimbursement Rules and Examples

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Reimbursement criteria and examples

UnitedHealthcare Community Plan will not reimburse services determined to be Incidental, Mutually Exclusive, Transferred, or Unbundled to a more comprehensive service unless the codes are reported with an appropriate modifier and meet coding guidance from authoritative sources.

ALL of the following

Services must be billed by the Same Individual Physician or Health Care Professional for the same member on the same date of service to be evaluated under this policy.
Rebundling edits are sourced from third‑party authoritative methodologies (CPT, CMS NCCI, CMS policy, specialty societies). Definitive sources are applied when explicit coding instructions exist; interpretive sources require mapping by clinical coding guidance.

ALL of the following

Designated modifiers recognized by this policy may permit separate reimbursement only when used according to correct coding guidelines from authoritative sources (e.g., CPT, CMS NCCI Policy Manual).
Examples of recognized modifiers
- Modifiers recognized include: 25, 50, 57, 58, 59, 78, 79, 91, E1–E4, LC, LD, LM, LT, RC, RI, RT, TA, T1–T9, FA–F9, XE, XP, XS, XU.
Modifiers do not universally bypass bundling edits; they only apply when consistent with third‑party coding guidance (example: CPT parenthetical prohibitions).

ALL of the following

Modifier 76 is inappropriate to indicate repeat laboratory services; use modifier 59, XE, XP, XS, XU, or 91 to indicate repeat or distinct laboratory services per AMA and CMS guidance.
Separate reimbursement will not be given for laboratory codes reported with modifier 76.

ALL of the following

Codes G2211 and G0545 for visit complexity are not separately reimbursed when billed with an Evaluation and Management (E/M) service for the same provider and date of service because visit complexity is included in E/M reimbursement.

ALL of the following

Incidental services (procedures that are performed with but are not essential to the primary procedure and typically do not require significant additional work/time) are not separately reimbursable.
Mutually exclusive services (coding combinations that represent two methods of performing the same service or cannot reasonably be done in the same session) are considered an error when submitted together; only the appropriate single code is allowed.
Transferred services are situations where the coding combination may be more appropriately reported with another code combination and should be reviewed against authoritative sources.
Unbundling (fragmenting a comprehensive service into component codes) is not reimbursed when the comprehensive code descriptor includes the component services per CCI or other definitive guidance.

Clinical examples and determinations

Total abdominal hysterectomy (58150) — codes such as salpingectomy (58700) and oophorectomy (58940) are not separately reportable when submitted with 58150 because 58150's descriptor includes those services (CCI source).
Examination under anesthesia (e.g., 57410, 92502) performed in the same anatomical area as a surgical procedure is integral to the surgical procedure and not separately reimbursable.
Vision screening CPT 99173 is not separately reimbursable with an E/M service (but is reimbursable with preventive service codes); follow the Preventive Medicine and Screening Policy for details.

ALL of the following

Rebundling edits are updated quarterly.
State‑specific fee schedule exceptions may allow separate reimbursement for particular codes in certain states; apply state fee‑schedule rules where applicable.
Certain HCPCS supply codes (e.g., A4550 surgical trays) are considered included in the practice expense of the E/M or procedure and not separately reimbursable per CMS guidance; see B Bundle policy for additional information.

Operational note: correct modifier selection

When reporting multiple procedures that may be distinct, select the modifier (e.g., 59, XE, XS, XP, XU) that most accurately describes the clinical circumstance; informational modifiers (e.g., LT) do not in themselves override bundling edits.

Recognized Codes and Modifiers

Recognized ModifiersModifier

25	Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service
50	Bilateral procedure
57	Decision for surgery
58	Staged or related procedure or service by the same physician during the postoperative period
59	Distinct procedural service
78	Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period
79	Unrelated procedure or service by the same physician during the postoperative period
91	Repeat clinical diagnostic laboratory test
XE	Separate Encounter; distinct encounter, a subset of modifier 59
XP	Separate Practitioner; distinct practitioner, a subset of modifier 59

1–10 of 43

1/5

E/M-related HCPCS (Not separately reimbursed)HCPCSNot Covered

G2211	Visit complexity—moderate to high (physician work) — not separately reimbursed when billed with an E/M service
G0545	Telephone evaluation and management service — visit complexity — not separately reimbursed when billed with an E/M service

Modifier Use and Edit Maintenance

Documentation Required

Use recognized modifiers correctly; edits updated quarterly

Use appropriate modifiers when reporting services that are altered; modifiers recognized by this policy may permit separate reimbursement only when used according to correct coding guidelines from authoritative sources. Rebundling edits are updated quarterly.

Recognized modifiers include: 25, 50, 57, 58, 59, 78, 79, 91, E1-E4, LC, LD, LM, LT, RC, RI, RT, TA, T1-T9, FA-F9, XE, XP, XS, XU (see policy list).
Modifiers do not universally bypass bundling; they only allow separate payment when used in accordance with CPT, CMS NCCI, CMS policy, or other authoritative coding guidance (example: CPT parenthetical prohibits reporting 29866 with 29885–29887 in same compartment).
Modifier 76 is inappropriate to indicate repeat laboratory services; use 59, XE, XP, XS, XU or 91 for repeat/distinct labs. Separate reimbursement will not be given for lab codes with modifier 76.
Rebundling edits (the rules that determine when codes are combined) are updated quarterly.

Key Term Definitions

inv-05: Unbundling — definition and examples

DefinitionUnbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code; an example is fragmenting one service into component parts and coding each component as if it were separate.

Typical scenarioBilling separate CPT/HCPCS codes for components of a single comprehensive surgical procedure instead of the single comprehensive code.

Policy effectServices determined to be Unbundled will not be reimbursed separately unless reported with an appropriate modifier and meet coding guidance.

inv-06: Incidental Services — definition and typical scenarios

DefinitionIncidental services are procedures that can be performed with the primary procedure but are not essential to complete it and typically do not have significant additional work or time; incidental procedures are not separately reimbursable.

Typical scenarioA minor procedure performed during a primary operative service that does not add significant time or work and is considered integral to the primary service.

Policy effectIncidental services will not be reimbursed separately unless reported with an appropriate modifier and meet coding guidance.

inv-07: Mutually Exclusive Services — definition and explanation

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

Typical scenarioTwo procedure codes that describe alternative methods for the same service being billed together for the same date of service and provider.

Policy effectMutually exclusive service combinations are not separately reimbursable and will be rebundled to the appropriate single code unless valid modifier documentation applies.

inv-08: Transferred Services — definition and context for reporting

DefinitionTransferred Services refers to situations where the coding combination may be more appropriately reported with another code combination or to a different CPT and/or HCPCS code(s).

Typical scenarioA service billed with one set of codes that should instead be reported using a different CPT/HCPCS code or code combination that more accurately describes the services performed.

Policy effectTransferred service combinations may be rebundled to the more appropriate code combination and will not be reimbursed separately unless modifiers and coding guidance support separate payment.

inv-09: Definitive vs Interpretive Source — distinction between source types

Definitive sourceA Definitive source is based on very specific instructions from the given source (e.g., explicit coding or modifier direction in CPT or CMS guidance).

Interpretive sourceAn Interpretive source is based on an interpretation of instructions from the identified source and requires mapping or clinical interpretation to apply to specific codes.

Policy useUnitedHealthcare Community Plan applies Definitive sources when explicit coding instructions exist and uses Interpretive sources when guidance requires interpretation to determine rebundling edits.

inv-10: Same Individual Physician or Other Qualified Health Care Professional — definition used for same-provider determination

Definition'Same Individual Physician or Other Qualified Health Care Professional' is the same individual rendering health care services reporting the same Federal Tax Identification number.

Operational implicationRebundling edits are applied to CPT/HCPCS codes reported together by the same individual provider for the same member on the same date of service.

Documentation requirementWhen multiple services are billed by the same provider on the same date, appropriate modifiers and correct coding guidance are required to permit separate reimbursement.