CurrentUnitedHealthcarePolicy 2025R0112A

Reimbursement for services billed on CMS-1500 (E/M services)

Defines UnitedHealthcare's reimbursement rules for services reported on the CMS-1500 form (and electronic equivalent) for Commercial and Individual Exchange plans, including which providers may report Evaluation and Management (E/M) services.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement for services billed on CMS-1500 (E/M services)

Policy CodePolicy 2025R0112A

Change TypeAdded CPT codestemplate update

Effective Date

Next Review Date

Key ActionDo not bill E/M (EIM) CPT codes under a nonphysician provider's own TIN; EIM codes must be reported only by physicians or qualified health care professionals (NP, CNS, CNM, PA).

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 98000-98016 to the policy.

Template updated to apply the policy to both UnitedHealthcare Commercial and Individual Exchange benefit plans.

CMS-1500claim form(s) governed

98000-98016 & 99202-99499EIM code range

Commercial & Exchangeplan types

1/12/2025history entry

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.

Evaluation and Management (E/M) Reimbursement Criteria

E/M reimbursement criteria

Reimbursement for Evaluation and Management (EIM) services is allowed only when billed by eligible provider types and using appropriate CPT/HCPCS codes; nonphysician providers must use codes specific to their profession.

Services billed with EIM CPT codes (e.g., 98000-98016, 99091, 99202-99499) are eligible for reimbursement only when reported by an eligible provider type.

ALL of the following

Eligible billers
- Physicians may report EIM CPT codes for reimbursement.
- Qualified health care professionals may report EIM CPT codes for reimbursement only when they are one of the following: nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse midwife (CNM), or physician assistant (PA).

ALL of the following

UnitedHealthcare will not reimburse EIM services when reported by nonphysician health care professionals filing under their own individual or group TIN.
For purposes of this policy, the specialties listed as nonphysician health care professionals (for example: audiology, registered dietitian/nutritionist, home health specialties, and many others) must not report EIM codes under their own TIN and should instead report profession-specific CPT/HCPCS codes (e.g., 97802 for Registered Dietitians, 92620 for Audiology).examples provided

Report the most comprehensive CPT code that describes the services performed in accordance with NCCI/CPT guidance; when a nonphysician health care professional performs a service, use the CPT/HCPCS code(s) that specifically and accurately identify that professional's services rather than EIM codes.

Applicable Codes and Provider Restrictions

E/M (EIM) codesCPT

98000-98016	EIM codes referenced in policy
99091	EIM related code referenced
99202-99499	EIM and wider evaluation and management code range referenced

Examples of appropriate non-physician codesCPT

97802	Medical Nutrition Therapy code (example alternative for Registered Dietitians)
92620	Audiology evaluation code referenced as appropriate alternative

Provider type restriction — who may report EIM codes

Allowed reporter typesPhysicians and qualified health care professionals: nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), and physician assistants (PA)

Excluded reporter typesNonphysician health care professionals billing under their own individual or group TIN will not be reimbursed for EIM codes

Applicable codesEIM CPT codes referenced: 98000-98016, 99091, 99202-99499

Billing and Reimbursement Actions for Providers

Billing Rule

Do not bill EIM CPT codes under nonphysician TINs — risk of nonpayment

UnitedHealthcare will not reimburse Evaluation and Management (EIM) services (CPT codes 98000-98016, 99091, 99202-99499) when those codes are reported by nonphysician health care professionals billing under their own individual or group TIN; EIM codes should only be reported by physicians or the qualified health care professionals listed (NP, CNS, CNM, PA).

Nonphysician specialties (e.g., audiology, registered dietitian, home health, etc.) are listed in the policy and should use codes specific to their profession rather than EIM codes.
Report the most comprehensive CPT code that describes the services performed per NCCI/CPT guidance; only physicians and NP/CNS/CNM/PA may report EIM codes for reimbursement.

Key Terms

Physician — definition

DefinitionPhysician — DO (physician as listed in Definitions section of the policy)

Role in EIM reportingPhysicians are authorized to report Evaluation and Management (EIM) CPT codes for reimbursement per policy guidance

Related guidanceCPT guidance and National Correct Coding Initiative require the most comprehensive CPT code that describes the services performed; physicians may report EIM codes as appropriate

Nonphysician health care professional — specialties & definition

DefinitionNonphysician health care professional — specialties considered nonphysician for this policy (examples include: Audiology; Nutritionist/Registered Dietitian; Home health aide; Licensed Practical Nurse; Social Worker; Counselor; Marriage & Family Therapy; Behavioral Analyst; Genetic Counselor)

Reimbursement ruleNonphysician health care professionals reporting under their own TIN will not be reimbursed for EIM codes; they should use CPT/HCPCS codes specific to their profession

Code alternativesThe policy notes there are CPT/HCPCS codes that specifically identify services performed by nonphysician professionals and gives examples (see coding guidance and example codes in other sections)

Policy Revision Notes

2025-01-12CPT additionsLatest

Added CPT codes 98000-98016 to the policy.

2024-04-01template update

Transferred content to shared policy template and updated Application section to apply the policy to UnitedHealthcare Commercial and Individual Exchange benefit plans.

2023-07-12branding update

Updated logo and archived history entries prior to 7/12/2021.

2010-03-14policy implementation

Policy implemented by UnitedHealthcare Employer & Individual.

2009-10-14policy approval

Policy approved by National Reimbursement Forum.