CurrentUnitedHealthcarePolicy 2025R9030A

CMS 1500 Modifier and Billing Reimbursement Rules

Governs UnitedHealthcare Medicare Advantage reimbursement rules for services billed on CMS 1500 forms, focusing on appropriate modifier use, specialty therapy and radiology modifier payment adjustments, and portable x-ray transportation modifiers; applies to network physicians and other qualified health care professionals serving Medicare Advantage members.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Modifier and Billing Reimbursement Rules

Policy CodePolicy 2025R9030A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionWhen billing services on CMS 1500 forms, append the appropriate modifier (e.g., GN/GO/GP for therapy, CQ/CO for PTA/OTA, CT/FX/FY for radiology TC reductions, or UN/UP/UQ/UR/US with R0075) to avoid denial or reduced payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS1500Forms covered

GN/GO/GPTherapy modifiers

CQ/COAssistant modifiers

CT/FX/FYRadiology TC reductions

UN–USR0075 modifiers

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Modifier and Billing Coverage Criteria

modifier and billing criteria

Reimbursement and billing rules summarized as actionable criteria:

UnitedHealthcare will consider reimbursement only when the modifier has been used appropriately with the procedure code; inappropriate modifier use may result in denial or non-reimbursement.

Modifier 25: report only with an Evaluation and Management (E/M) service; appending modifier 25 to non-E/M codes (for example a surgical code) will not be reimbursed.

Therapy 'always' codes must be reported with one of the therapy discipline modifiers GN, GO, or GP; claims without one of these designated modifiers will be rejected.

When services are furnished in whole or in part by a PTA or OTA, the CQ (PTA) or CO (OTA) modifier must be appended on the service line alongside the respective GP or GO therapy modifier where applicable.

For providers reimbursed under Medicare Fee-for-Service contract agreements, services reported with CQ or CO (when applicable) will be paid at 85% of the otherwise applicable Part B payment amount per CMS final rule implementation.

Appending radiology reduction modifiers CT, FX, or FY to radiology services will trigger reductions to the technical component (TC) payment or the TC portion of the global fee per the specified percentages and effective dates.

HCPCS R0075 (portable x‑ray transportation) must be billed with one of the modifiers UN, UP, UQ, UR, or US to indicate the number of patients served; R0075 billed without an applicable modifier will be denied.

When reporting R0075 with U*N modifiers the total payment shall be divided per modifier: UN = divide by 2; UP = divide by 3; UQ = divide by 4; UR = divide by 5; US = divide by 6 (US applies regardless of actual patients served if more than six).

Codes and Modifier Tables

modifier appropriatenessModifierCovered

25	Modifier 25 should be reported only with Evaluation and Management (E/M) services; inappropriate use with non-E/M codes will not be reimbursed.

therapy discipline modifiersModifierCovered

GN	Speech-language pathology therapy modifier required on designated CPT/HCPCS codes.
GO	Occupational therapy modifier required on designated CPT/HCPCS codes.
GP	Physical therapy modifier required on designated CPT/HCPCS codes.

assistant modifiersModifierCovered

CQ	Modifier for services furnished in whole or in part by a physical therapist assistant (PTA); required when applicable and used with GP.
CO	Modifier for services furnished in whole or in part by an occupational therapy assistant (OTA); required when applicable and used with GO.

radiology reduction modifiersModifierCovered

CT	Modifier for CT scans on non-NEMA XR-29-2013-compliant equipment; triggers 15% reduction to TC payment portion.
FX	Modifier for film X-ray services; triggers TC payment reduction (20% beginning Jan 1, 2017).
FY	Modifier for cassette-based imaging; TC payment reductions phased: 20% (2017), 7% (2018–2022), 10% (beginning Jan 1, 2023).

transportation componentHCPCSCovered

R0075

Portable x-ray transportation HCPCS code must be reported with UN/UP/UQ/UR/US to indicate number of patients served; payment divided per modifier rules (UN=divide by 2; UP=divide by 3; UQ=divide by 4; UR=divide by 5; US=divide by 6 regardless of actual patients if >6).

R0075 payment divisor rules — UN/UP/UQ/UR/US

UNWhen appended to R0075, total payment for the service is divided by 2.

UPWhen appended to R0075, total payment for the service is divided by 3.

UQWhen appended to R0075, total payment for the service is divided by 4.

URWhen appended to R0075, total payment for the service is divided by 5.

USWhen appended to R0075, total payment for the service is divided by 6 (applies regardless of actual number of patients if more than 6).

Provider Action Notes

Prior Authorization

Prior Authorization Note — Check member benefits or customer service

UnitedHealthcare Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements; for enrollee‑specific coverage or prior authorization information, consult the member's benefit documents or contact customer service using the number on the back of the member ID card.

Policy text: UnitedHealthcare's Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements.
For enrollee‑specific prior authorization or coverage details, call the customer service number on the member ID card or check benefit documents.

Definitions and Source Types

Definitive Source — definition

DefinitionA Definitive Source is based on very specific instructions from the given source and contains exact codes, modifiers, or precise operational instructions.

UsageUnitedHealthcare Medicare Advantage relies on Definitive Sources to determine exact procedure code-to-modifier relationships for reimbursement determinations.

ImplicationWhen a Definitive Source specifies a modifier requirement, reimbursement will be considered only when that exact modifier is used appropriately with the procedure code.

Interpretive Source — definition

DefinitionAn Interpretive Source is based on an interpretation of instructions from an identified source and does not provide exact code/modifier pairings, requiring judgment to correlate guidance to specific codes.

Usage