CurrentUnitedHealthcarePolicy 2025R7131E

Reimbursement Policy CMS-1500 and UB04

Policies governing appropriate diagnosis coding, placement, and reimbursement rules for claims submitted on CMS-1500 and UB-04 claim forms for UnitedHealthcare Community Plan; includes state exceptions and attachments of inappropriate primary ICD-10 diagnosis code lists.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy CMS-1500 and UB04

Policy CodePolicy 2025R7131E

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims using codes that correctly describe services; UnitedHealthcare may use discretion in applying this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500/UB-04claim forms covered

multiplestate exceptions

ICD-10 listsattachments

presentQ&A

Primary Diagnosis and Denial Criteria

Primary diagnosis coding and denial criteria

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy CMS-1500 and UB04

Policy CodePolicy 2025R7131E

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims using codes that correctly describe services; UnitedHealthcare may use discretion in applying this policy.

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.

Primary/principal diagnosis must be submitted in the appropriate claim form field for the claim type (CMS-1500 box 24E for professional claims; UB-04 box 67 for outpatient institutional claims).

If an inappropriate diagnosis code from the Inappropriate Primary Diagnosis Codes list is pointed to/linked as the primary diagnosis on a CMS-1500 (box 24E), only the claim line(s) associated with that improperly reported primary diagnosis will be denied.

If an inappropriate principal diagnosis code from the Inappropriate Primary Diagnosis Codes list is submitted as the principal diagnosis in box 67 of the UB-04, the entire claim will be denied.

Certain codes (for example, manifestation codes, Excludes1-related codes, specific Z codes and external cause codes) have restrictions and cannot be used as the first-listed or principal diagnosis; follow the ICD-10-CM Official Guidelines for Coding for applicable coding conventions and Excludes1 rules.

State-specific exceptions may apply; where documented, state exceptions override portions of this policy.

Coding Guidance and Examples

Coding guidance examples and categoriesICD-10

T86	Complications of transplanted organs and tissue (used first for malignant neoplasm of transplanted organ)
Z51.89	Example of principal diagnosis requiring a secondary diagnosis be submitted

Sequela and related coding examplesICD-10

Sequela coding	Generally requires two codes: condition/nature first, sequela second (exceptions exist where sequela is followed by manifestation or includes manifestation)
External cause codes (V00-Y99)	Should not be used as principal diagnosis; describe how injury/health condition occurred and intent
Factors influencing health status (Z codes)	Certain Z codes may be used as first listed/principal diagnosis; others only as secondary depending on encounter
R65	Sepsis, Severe Sepsis, and Septic Shock (category referenced)

Sequela coding requirement

Sequela coding orderGenerally requires two codes: assign the condition or nature of the sequela first, and the sequela code second (exceptions apply when the sequela code is followed by a manifestation code or the sequela code already includes the manifestation).

Exception — sequela followed by manifestationWhen the sequela code is followed by a manifestation code, sequence per coding guidance (sequela may appear before manifestation).

Exception — sequela expanded to include manifestationIf the sequela code has been expanded to include the manifestation(s), a separate manifestation code is not required and sequencing follows that code structure.

Related coding exampleCode malignant neoplasm of a transplanted organ as a transplant complication: assign T86 (complications of transplanted organs and tissue) first, followed by C80.2.

Key Definitions

Manifestation codes

DefinitionManifestation codes describe the manifestation of an underlying disease and cannot be reported as the first listed or principal diagnosis.

Code first notesWhen a 'code first' note is present for certain codes (not manifestation codes), the underlying condition is sequenced first, if known.

Reference guidanceConsult the ICD-10-CM Official Guidelines for Coding and Reporting for full descriptions and sequencing rules for manifestation codes.

Excludes1 note definition

Excludes1 note meaningAn Excludes1 note indicates that the excluded code should never be used at the same time as the code above the Excludes1 note.

ApplicationUse Excludes1 guidance to identify mutually exclusive diagnosis codes and prevent coding both conditions on the same claim.

Where foundExcludes1 notes appear in ICD-10-CM code listings and are referenced in the policy's reimbursement guidelines.

Provider Responsibilities and Denial Behavior

Documentation Required

Submit accurate claims using correct diagnosis codes

You are responsible for submission of accurate claims. Submit claims using the code or codes that correctly describe the health care services provided; UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy and system or regulatory factors may affect implementation.

Denial Risk

Denial behavior when inappropriate diagnosis is placed as primary/principal

If an inappropriate diagnosis code is pointed to or linked as the primary diagnosis on a CMS-1500 (box 24E), only the claim line(s) associated with that diagnosis will be denied. If an inappropriate principal diagnosis code is submitted in box 67 of a UB-04, the entire claim will be denied.

CMS-1500 professional claims: denial limited to affected line(s) when inappropriate code is linked in box 24E.
UB-04 outpatient claims: entire claim denied when inappropriate principal diagnosis is placed in box 67.