CurrentUnitedHealthcarePolicy 2025R9052A

Reporting of Habilitative and Rehabilitative Services (Modifiers 96/97)

This policy governs how habilitative and rehabilitative services should be reported on claims (CMS 1500 and UB-04) for UnitedHealthcare Individual Exchange products and which modifiers to use; it affects providers submitting outpatient and facility claims for those products.

Policy Summary

PayerUnitedHealthcare

PolicyReporting of Habilitative and Rehabilitative Services (Modifiers 96/97)

Policy CodePolicy 2025R9052A

Change TypeNo material change

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

No material clinical or coverage changes in this revision.

96 & 97Modifiers required to differentiate habilitative vs rehabilitative services

RejectedRejected claim lines

CMS1500/UB-04Claim forms covered

MultipleExcluded states

GP/GO/GNTherapy discipline modifiers

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Habilitative and Rehabilitative Billing Criteria

Habilitative/Rehabilitative billing criteria

Billing and applicability rules for habilitative and rehabilitative services

ALL of the following

Claims for habilitative services must be billed with the appropriate CPT/HCPCS code and modifier 96 to identify habilitative services.
Claims for 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; combinations of 96 and 97 on a single line are not allowed and 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 services are 'always therapy services,' continue to append therapy-discipline modifiers in addition to 96/97 as applicable (GN for speech therapy, GO for occupational therapy, GP for physical therapy).
If a manipulative service in a specific state is not considered habilitative or rehabilitative in nature, the 96 or 97 modifier is not required for that service.
This policy applies to UnitedHealthcare Individual Exchange products and to claims submitted on CMS 1500 or UB-04 forms (including electronic equivalents) for outpatient providers and facilities; it does not apply to Individual Exchange plans in specified excluded states.

Refer to the policy code lists for applicable CPT/HCPCS pairings and the manipulative code applicability by state.

OT / PT / SLP and Manipulative Procedure Codes

OT / PT / SLP codes (paired mapping list)mixed

92508	Audiology diagnostic evaluation/therapy (paired mappings shown)
92521	Evaluation of speech fluency; mapping pairs
92522	Evaluation of speech sound production; mapping pairs
92523	Language comprehension/expressive; mapping pairs
92524	Voice/resonance evaluation; mapping pairs
92526	Speech therapy, per session; mapping pairs
92597	Speech/hearing therapy, miscellaneous; mapping pairs
92606	Assistive listening device evaluation; mapping pairs
92609	Auditory rehabilitation; mapping pairs
92610	Speech generating device assessment; mapped to multiple codes

1–10 of 16

1/2

Mapped code pairs and replacementsmixed

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

1–10 of 54

1/6

Partial / unspecified mappings (state-specific)mixed

V5363 + 92508	state-specific mapping (details unspecified)
V5363 + 92521	state-specific mapping (unspecified)
V5363 + 92522	state-specific mapping (unspecified)
V5363 + 92523	state-specific mapping (unspecified)
V5363 + 92524	state-specific mapping (unspecified)
V5363 + 92526	state-specific mapping (unspecified)
V5363 + 92597	state-specific mapping (unspecified)
V5363 + 92606	state-specific mapping (unspecified)
V5363 + 92609	state-specific mapping (unspecified)

Manipulative therapy code pairs (state-applied list)CPT

98925	Chiropractic manipulative treatment (CMT) — level 1 (paired mappings)
98926	Chiropractic manipulative treatment — level 2 (mapped from 98925 when modifier/position = 1)
98928	CMT — level 3 (mapped from 98925 when modifier/position = 3)
98929	CMT — level 4 (mapped from 98925 when modifier/position = 4)
98940	Spinal, pelvis and/or sacroiliac joint manipulation (mapped from 98925 position 5)
98941	Extra-spinal manipulation (mapped from 98925 position 6)
98942	Manipulation, other region (mapped from 98925 position 7)
98943	Further manipulative code (mapped from 98925 position 8)

Modifier Use and Billing Rules for Providers

Billing Rule

Use modifier 96 for habilitation and 97 for rehabilitation; avoid using both

Claims for habilitative services must be billed with the appropriate CPT/HCPCS code and modifier 96; claims for rehabilitative services must be billed with the appropriate CPT/HCPCS code and modifier 97. Do not bill both modifier 96 and 97 on the same claim line; claim lines without either modifier or with both will be rejected as incorrect coding.

Use modifier 96 to identify habilitative services on the CPT/HCPCS line item.
Use modifier 97 to identify rehabilitative services on the CPT/HCPCS line item.
Do not report both 96 and 97 on the same claim line; such lines will be rejected.
Lines missing either modifier when required will be rejected as incorrect coding.

Billing Rule

Continue to append therapy discipline modifiers (GN/GO/GP) when applicable

Key Definitions

Habilitative and Rehabilitative Services

Habilitative services (definition)Help an individual learn, keep, or improve skills and functioning for daily living that the individual has not developed; same CPT/HCPCS codes may be used for habilitative services when identified with modifier 96.

Rehabilitative services (definition)Help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired due to illness or injury; same CPT/HCPCS codes may be used for rehabilitative services when identified with modifier 97.

Purpose of modifiers 96 and 97Modifiers 96 and 97 were developed to differentiate when the same CPT/HCPCS codes are used for habilitative versus rehabilitative services.

Billing consequence for missing or conflicting modifiersClaim lines billed without either modifier 96 or 97, or billed with both 96 and 97 on the same claim line, will be rejected as incorrect coding.

ApplicabilityApplies to reporting of habilitative and rehabilitative services on claims (CMS 1500/UB-04) for UnitedHealthcare Individual Exchange products.