CurrentUnitedHealthcarePolicy 2025R9064A

UnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500 UB04

Defines UnitedHealthcare Medicare Advantage reimbursement requirements for submitting appropriate ICD-10-CM principal/primary diagnoses on UB-04 (facility) and CMS-1500 (professional) claim forms and the consequences of inappropriate diagnosis placement; applies to providers submitting claims to UnitedHealthcare Medicare Advantage.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500 UB04

Policy CodePolicy 2025R9064A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionEnsure ICD-10-CM diagnosis codes are sequenced per the official guidelines and place principal diagnosis in UB-04 Box 67 or primary diagnosis in CMS-1500 Box 24E to avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UB-04 Box 67required location for inpatient principal diagnosis

CMS-1500 Box 24Erequired diagnosis pointer location for professional primary diagnosis

Excludes1Excludes1 guidance

Reimbursement Coding and Claim Placement Requirements

Reimbursement coding and claim placement criteria

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500 UB04

Policy CodePolicy 2025R9064A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionEnsure ICD-10-CM diagnosis codes are sequenced per the official guidelines and place principal diagnosis in UB-04 Box 67 or primary diagnosis in CMS-1500 Box 24E to avoid claim denials.

SourceLink

On This Page

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Submit diagnosis coding and sequencing in accordance with the ICD-10-CM Official Guidelines for Coding and Reporting (CMS/NCHS).

Do not report manifestation codes as first‑listed or principal diagnosis when they represent manifestations of an underlying disease; sequence the underlying condition first.

Manifestation guidance per ICD-10-CM Official Guidelines.

Follow 'code first' sequencing when a 'code first' note applies: the underlying condition is sequenced first when known.

Sequela coding: generally report two codes — the condition/nature of the sequela first, then the sequela code second, except where the guidelines specify otherwise (e.g., sequela code followed by manifestation or expanded sequela code).

For malignant neoplasm of a transplanted organ, assign the appropriate T86 code (complications of transplanted organs and tissue) first, followed by C80.2.

For conditions caused by external or toxic agents, assign the agent code (T51-T65) first, then the condition code; in pregnancy assign the toxic effect code first, then the pregnancy code.

Do not use external cause codes (V00-Y99) as the principal diagnosis; these codes describe how an injury/condition occurred and the intent and are not appropriate as first‑listed/principal diagnosis.

Z codes (Z00-Z99) may be first‑listed or secondary depending on the circumstance; consult ICD-10-CM guidance to determine if a particular Z code may be used as the principal/first‑listed diagnosis.

Sepsis, severe sepsis, and septic shock coding follow Category R65 guidance per ICD-10-CM; sequence per the official guidelines.

Do not assign mutually exclusive codes indicated by an Excludes1 note together; an Excludes1 indicates the excluded code should never be used at the same time as the code above the Excludes1 note.

Excludes1 definition

ALL of the following

Inpatient facility claims (UB‑04): Principal diagnosis must be submitted in Box 67 (or electronic equivalent).
Outpatient facility claims (UB‑04): Diagnosis must be submitted in Box 67 (or electronic equivalent).
Professional claims (CMS‑1500): Primary diagnosis is the diagnosis pointer in Box 24E; the diagnosis pointed to or linked as primary determines line‑level reimbursement eligibility.

ALL of the following

If an inappropriate diagnosis code is linked as primary on a CMS‑1500, only the associated claim line(s) will be denied.
If an inappropriate principal diagnosis is submitted in Box 67 of a UB‑04, the entire claim will be denied.

ALL of the following

When a principal diagnosis requires a secondary diagnosis be submitted (for example Z51.89), include the required secondary diagnosis as specified by ICD-10-CM.

Denial Behavior and Provider Implications

Denial Risk

Denial behavior for inappropriate primary/principal diagnosis

If an inappropriate diagnosis is recorded as the primary/primary-linked diagnosis on a professional (CMS-1500) claim, only the claim line(s) associated with that diagnosis pointer in Box 24E will be denied. If an inappropriate principal diagnosis is submitted in Box 67 of a UB-04 (inpatient) claim, the entire claim will be denied.

CMS-1500: Denial applies only to the line(s) linked to the inappropriate primary diagnosis in Box 24E.
UB-04: Denial of the entire claim occurs when an unacceptable principal diagnosis is reported in Box 67.

Key Term Definitions

Excludes1 — definition and guidance

Excludes1 — meaning'NOT CODED HERE!' — indicates the excluded code should never be used at the same time as the code above the Excludes1 note.

Coding implicationWhen an Excludes1 appears, do not assign the excluded code in any position on the claim if the related code (the one with the Excludes1 note) is also reported.

Claim-level effectExcludes1 guidance prevents co-reporting of mutually exclusive codes to ensure accurate sequencing and reimbursement.

Primary Diagnosis — definition

DefinitionThe diagnosis to which the majority of the resources were applied.

Claim sequencing relevanceOn professional (CMS-1500) claims, the primary diagnosis should be the condition that consumed most resources and be placed in the required diagnosis pointer (e.g., Box 24E as applicable).

Denial consequenceIf an inappropriate primary diagnosis is submitted on CMS-1500 only the associated claim line(s) will be denied per policy rules.

Principal Diagnosis — definition (UHDDS)

UHDDS definitionThe principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Claim placementFor inpatient facility claims the principal diagnosis must be reported in the required UB-04 field (Box 67) as the condition driving the admission.

Denial consequenceIf an unacceptable principal diagnosis is submitted in Box 67 of a UB-04 the entire claim may be denied under this policy.

OpenPayer

UnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500 UB04

Reimbursement Coding and Claim Placement Requirements

Illustrative ICD-10-CM Codes Referenced

Denial Behavior and Provider Implications

Key Term Definitions

V00-Y99	External causes of morbidity — not to be used as principal diagnosis
Z00-Z99	Factors influencing health status (Z codes) — may be first or secondary depending on encounter
T86	Complications of transplanted organs and tissue — code first for malignant neoplasm of transplanted organ
C80.2	Malignant neoplasm of transplanted organ (used after T86)
R65	Sepsis, severe sepsis, and septic shock coding considerations