CurrentUnitedHealthcarePolicy 2025R9052A

Billing for habilitative vs rehabilitative services (Modifiers 96/97)

Defines how to report habilitative and rehabilitative services on CMS-1500/UB-04 claims for UnitedHealthcare Individual Exchange products, including required modifiers and prohibited modifier combinations.

Policy Summary

PayerUnitedHealthcare

PolicyBilling for habilitative vs rehabilitative services (Modifiers 96/97)

Policy CodePolicy 2025R9052A

Change TypeNon-material/version update

Effective Date

Next Review Date

Key ActionBill habilitative services with modifier 96 and rehabilitative services with modifier 97; do not bill both on the same claim line.

SourceLink

POLICY UPDATE CHANGES

Anniversary review and version change recorded on 5/25/2025.

Updated application language on 4/14/2024.

Added new 2024 states that are excluded from this policy on 1/1/2024.

2required modifiers (96 for habilitative; 97 for rehabilitative)

1prohibited modifier combination (96 and 97 on same claim line)

15states listed for OT/PT/ST code list

14states excluded from policy

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Reporting and billing criteria

Claim submission requirements and prohibitions

Habilitative services must be billed with the appropriate CPT/HCPCS code and modifier 96 to identify habilitative services.

Rehabilitative services must be billed with the appropriate CPT/HCPCS code and modifier 97 to identify rehabilitative services.

Do not bill both modifiers 96 and 97 on the same claim line; claim lines billed with both modifiers on the same line will be rejected as incorrect coding.

Claim lines for habilitative or rehabilitative services billed without either modifier 96 or 97 will be rejected as incorrect coding.

When the service is an 'always therapy' service, continue to append discipline modifiers GN (speech), GO (occupational), or GP (physical) as applicable in addition to modifier 96 or 97.

Application: This policy applies to UnitedHealthcare Individual Exchange products and to services reported on CMS-1500, UB04 or electronic equivalents, and applies to in-network and out-of-network providers and specified outpatient/ASC/OSC settings.

Modifiers and Code Guidance

Modifiers (billing rules)ModifierCovered

96	Modifier to identify Habilitative services
97	Modifier to identify Rehabilitative services

Paired CPT/HCPCS Mapping (selected pairs)mixedCovered

92610 + 92508	maps to 92611
92610 + 92521	maps to 92612
92610 + 92522	maps to 92626
92610 + 92523	maps to 92627
92610 + 92524	maps to 92630
92610 + 92526	maps to 92633
92610 + 92597	maps to 93668
92610 + 92606	maps to 93797
92610 + 92609	maps to 93798
94667 + 92508	maps to 94668

1–10 of 45

1/5

Additional HCPCS/G- and S- Code mappingsmixedCovered

97799 + 92508	maps to 0552T
97799 + 92521	maps to G0237
97799 + 92522	maps to G0238
97799 + 92523	maps to G0239
97799 + 92524	maps to G0281
97799 + 92526	maps to G0283
97799 + 92606	maps to G0303
97799 + 92609	maps to G0304
97799 + 92597	maps to G0302
G0305 + 92508	maps to G0422

1–10 of 19

1/2

Manipulative Codes (applicable FL, GA, MI, MS, NC, VA, and TX Consumer Choice)CPTCovered

98925	Chiropractic manipulative treatment; 1-2 regions
98926	Chiropractic manipulative treatment; 3-4 regions
98927	Chiropractic manipulative treatment; 5 regions
98928	Chiropractic manipulative treatment; 1-2 regions, additional sessions
98929	Chiropractic manipulative treatment; 3-4 regions, additional sessions
98940	Chiropractic manipulative treatment, spinal, 1-2 regions
98941	Chiropractic manipulative treatment, spinal, 3-4 regions
98942	Chiropractic manipulative treatment, spinal, 5 regions
98943	Chiropractic manipulative treatment, extras

Modifier Combination Rule

Billing Requirements and Applicability

Billing Rule

Modifier billing requirements

Claims for Habilitative Services should be billed with the appropriate CPT/HCPCS code and modifier 96 to identify habilitative services. Claims for Rehabilitative Services should be billed with the appropriate CPT/HCPCS code and modifier 97 to identify rehabilitative services. Do not bill both modifiers 96 and 97 on the same claim line. Claim lines billed without modifier 96 or 97, or billed with both modifiers on the same line, will be rejected as incorrect coding.

Bill habilitative services with Modifier 96.
Bill rehabilitative services with Modifier 97.
Do not bill both Modifier 96 and Modifier 97 on the same claim line.
Claims without Modifier 96 or 97, or with both modifiers on one line, will be rejected.

Note

Application and affected providers

This reimbursement policy applies to UnitedHealthcare Individual Exchange products. It applies to services reported using the CMS-1500 (1500 Health Insurance Claim Form), UB-04 claim form or electronic equivalents (or successor forms). This policy applies to all products and to services by network and non-network physicians and other qualified health care professionals, outpatient facilities, Ambulatory Surgical Centers (ASC), Outpatient Surgical Centers (OSC), including non‑network authorized and percent‑of‑charge contract physicians and other qualified providers or facilities.

Applies to UnitedHealthcare Individual Exchange products.
Applies to claims submitted on CMS-1500, UB-04 or electronic equivalents.
Applies to all products, network and non-network physicians and other qualified health care professionals, outpatient facilities, ASC and OSC.

Key Definitions

Habilitative Services

DefinitionHabilitative services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep and/or improve those learned skills.

BillingBill habilitative services with the appropriate CPT/HCPCS code and modifier 96 to identify habilitative intent.

PurposeUsed to document services provided to teach patients new skills needed for functions of daily living.

Rehabilitative Services

DefinitionRehabilitative services help restore skills and functioning for daily living that have been lost or impaired due to disease, injury, or disability.

BillingBill rehabilitative services with the appropriate CPT/HCPCS code and modifier 97 to identify rehabilitative intent.

PurposeUsed to document services provided to reteach a patient skill needed for functions of daily living that have been lost.

Modifier 96

TermModifier 96 is a CPT modifier used to identify services provided to teach patients new skills needed for functions of daily living (habilitative).

Use on claimsAppend modifier 96 to the appropriate CPT/HCPCS code when billing habilitative services on UnitedHealthcare Individual Exchange claims.

InteractionDo not combine modifier 96 with modifier 97 on the same claim line; such combinations will be rejected.

Modifier 97

TermModifier 97 is a CPT modifier used to identify services provided to reteach a patient skill needed for functions of daily living that have been lost (rehabilitative).

Use on claimsAppend modifier 97 to the appropriate CPT/HCPCS code when billing rehabilitative services on UnitedHealthcare Individual Exchange claims.

InteractionDo not combine modifier 97 with modifier 96 on the same claim line; such combinations will be rejected.

Policy Changes and History

2025-05-25anniversary reviewLatest

Anniversary review and version change recorded; earlier entries prior to 2023 were archived.

2024-04-14version change

Policy version changed with updated application language.

2024-01-01version change

Policy version changed to add states excluded from the policy effective 1/1/2024.

2022-01-01policy implementation

Policy implemented by UnitedHealthcare Individual Exchange.