CurrentUnitedHealthcarePolicy N/A

Maximum Frequency Per Day (MFD) — reimbursement limits for CPT/HCPCS units

Defines UnitedHealthcare Community Plan Medicaid reimbursement rules for maximum frequency per day (MFD) for CPT and HCPCS codes billed by physicians and other qualified health care professionals; includes national methodology and many state-specific exceptions. Applies to Community Plan Medicaid products and most providers except specified exclusions.

Policy Summary

PayerUnitedHealthcare

PolicyMaximum Frequency Per Day (MFD) — reimbursement limits for CPT/HCPCS units

Policy CodePolicy N/A

Change TypeHistory log of attachment and state exception updates (2023–2024)

Effective DateN/A

Next Review DateN/A

Key ActionMonitor the referenced attachment lists and state exception sections for specific MFD CPT/HCPCS codes, modifier restrictions, and state-specific frequency rules and apply appropriate modifiers (59, 76, 91, XE, XS, XU) when units billed exceed MFD.

SourceLink

POLICY UPDATE CHANGES

Multiple entries record frequent updates to attachment lists (Arizona MFD CPT and HCPCS lists, MFD CPT code list, MFD HCPCS list, and modifier LT/RT restriction lists) and state exceptions across many dates in 2023–2024.

MUE> MFDHierarchy of edits applied

100Default MFD for new codes

999Default MFD for unlisted codes

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.

Low volume threshold

200+Approx. change-log entries

Maximum Frequency Per Day (MFD) Determination Logic

Logic to determine MFD value

Stepwise criteria applied to set MFD when CMS MUE not applicable

ANY of the following

If CMS MUE exists, use CMS MUE (except AZ where state list may override)
If code descriptor references 'once per' or 'per day', set MFD = 1
If service is classified bilateral (Indicator 3) or descriptor includes 'bilateral', set MFD = 1 unless other criteria apply
If service is anatomically or clinically limited, set MFD at that clinical limit
If CPT/HCPCS descriptor indicates allowable number, set MFD to that number
If DME MAC LCD assigns MFD, use that value
If no definitive value and code is a drug HCPCS (no prior criteria), special drug HCPCS handling applies
Unlisted CPT/HCPCS codes default to MFD = 999 (exempt)
New CPT/HCPCS codes since last MFD update default to MFD = 100

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Code Groups, Modifiers, and Referenced Attachments

Modifiers that may allow additional reimbursement when MFD exceededModifier

59	Distinct procedural service — may support additional units
76	Repeat procedure by same physician
91	Repeat clinical diagnostic laboratory test
XE	Separate encounter
XS	Separate structure
XU	Unusual non-overlapping service
LT/RT	Laterality modifiers — informational for many codes; payment up to MFD regardless of LT/RT

Examples of CPT/HCPCS codes referenced (not exhaustive)mixed

90460	Immunization administration; with counseling — guidance on reporting multiple components
90461	Immunization administration; additional vaccine component
95165	Allergen-specific immunotherapy dose — CMS dose definition and MUE reference
99509	Home health-related code referenced in state exceptions
T1019	State exceptions commonly allow up to 96 units/day

Referenced attachment lists (present in change-log)mixed

	Arizona Maximum Frequency Per (MFD) CPT and HCPCS Policy List (attachment referenced multiple times)
	Maximum Frequency Per Day (MFD) CPT Code Policy List (attachment referenced)
	Maximum Frequency Per (MFD) HCPCS Policy List (attachment referenced)
	Maximum Frequency Per (MFD) Codes Restricting Modifiers LT and RT Policy List (attachment referenced)
	Washington DC Maximum Frequency Per (MFD) CPT and HCPCS Policy List (attachment referenced)

Billing, Submission, and Documentation Requirements

Documentation Required

Modifier use and documentation

When units billed exceed the MFD, appropriate modifiers (59, 76, 91, XE, XS, XU) may be reported to indicate distinct services. Medical records are not required to be submitted with the claim when modifiers 59, 76, 91, XE, XS or XU are appropriately reported, but documentation must support the modifier if the claim is appealed.

Billing Rule

Submission rules for immunizations and per‑day codes

Numeric Thresholds and Statistical Rules

MFD Thresholds

Low volume claim occurrences threshold50 occurrences (if <50 → MFD =100)

Percentile ruleMFD = 100th percentile unless 100th > (4 × 98th), then MFD = 98th percentile

Default for new codes100 units

Default for unlisted codes999 units (exempt)

Key Terms

Definitions

MFD (Maximum Frequency per Day)The highest number of units eligible for reimbursement for a CPT or HCPCS code on a single date of service by the same individual provider.

MUE (Medically Unlikely Edit)CMS-established maximum units per day; supersedes MFD values except where state-specific rules apply (Arizona exception noted).

Same individual providerThe same individual rendering services and reporting the same Federal Tax Identification Number.

Scope and Purpose

This policy defines UnitedHealthcare Community Plan Medicaid reimbursement rules for Maximum Frequency per Day (MFD) for CPT and HCPCS codes billed by physicians and other qualified health care professionals. It establishes MFD as the highest number of units eligible for reimbursement for a single CPT or HCPCS code on a single date of service by the same individual provider, and it applies to UnitedHealthcare Community Plan Medicaid products (see Application).

The document implements a national methodology to set MFD values and explicitly recognizes numerous state-specific exceptionsMUE) values first (MUE values supersede MFD except where a state (for example, Arizona) publishes its own unit limits). When CMS MUEs are not applicable, the policy applies a hierarchy of criteria — code descriptor language (e.g., 'once per' or 'per day'), bilateral indicators, anatomical or clinical limits, CMS DME MAC LCD values, and specific code descriptors — to determine MFD values.

When the Part I criteria do not provide an MFD value, a data-driven approach is used: codes with fewer than 50 occurrences in the claims dataset default to MFD = 100; codes with ≥50 occurrences are set to the observed 100th percentile (the maximum units billed) unless the 100th percentile exceeds four times the 98th percentile, in which case the MFD is set to the 98th percentile. New CPT/HCPCS codes default to MFD = 100, and unlisted codes default to MFD = 999 (exempt).

Providers should note operational rules: MFD applies whether units are submitted as multiple units on one line or across multiple lines; appropriate modifiers (e.g., 59, 76, 91, XE, XS, XU) may be used to indicate distinct services when billed units exceed the MFD and, if used properly, medical records are not required with the claim but must support modifier use on appeal. State attachment lists contain the specific CPT/HCPCS MFD assignments and modifier restrictions and are updated frequently — consult those attachments for state exceptions and code‑specific values.

Change Log Summary

12/17/2023Attachment update

Arizona Maximum Frequency Per (MFD) CPT and HCPCS Policy List updated; history entries prior to 12/17/2021 archived.

11/05/2023State exception update

Ohio State Exceptions section updated and attachments including Codes Restricting Modifiers LT and RT, CPT and HCPCS MFD lists updated.

1/14/2024Attachment update

Arizona MFD CPT and HCPCS Policy List updated; history entries prior to 1/21/2022 archived.

Policy Summary

PayerUnitedHealthcare

PolicyMaximum Frequency Per Day (MFD) — reimbursement limits for CPT/HCPCS units

Policy CodePolicy N/A

Change TypeHistory log of attachment and state exception updates (2023–2024)

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

For immunization administration codes 90460 and 90461, providers may report multiple vaccine components either on one line with multiple units or on separate lines; however, reporting the same CPT/HCPCS code on multiple lines may trigger duplicate-line edits and could result in denials.

90460
90461
Note: duplicate-line edits may apply and could cause denials when the same code is reported on multiple lines

Billing Rule

Laterality modifiers LT/RT handling

Laterality modifiers LT and RT are considered informational for codes on the 'Codes Restricting Modifiers LT and RT' list; UnitedHealthcare will pay up to the MFD value regardless of LT/RT and will not allow LT/RT to increase the MFD where laterality does not apply.

Documentation Required

Monitor attachment list updates and state exceptions

Monitor the referenced attachment lists and state-specific exception sections for code-level MFD values, modifier restrictions, and state frequency rules; this part of the document functions as a change history log showing frequent updates to attachment lists and state exceptions.

This document's history records frequent updates to attachment lists (e.g., Arizona MFD CPT and HCPCS lists, MFD CPT code list, MFD HCPCS list, Codes Restricting Modifiers LT and RT) and state exceptions.
Providers should review the attachments and state exceptions for specific MFD values and modifier restrictions applicable to their state.

1/21/2024Attachment update

Arizona MFD CPT and HCPCS Policy List and the Maximum Frequency Per (MFD) CPT and HCPCS Policy Lists updated.

3/10/2024Attachment and state updates

Attachment Section: Arizona MFD CPT and HCPCS Policy List updated; State Exceptions section: Washington updated; history entries prior to 3/10/2022 archived.

6/09/2024Attachment and state updates

Attachment Section: Arizona MFD CPT and HCPCS Policy List updated; State Exceptions section: Washington and New Jersey updated.

7/14/2024Attachment update

Attachment Section: Arizona MFD CPT and HCPCS Policy List updated; history entries to 7/14/2022 archived.

8/04/2024Attachment updates

Attachment lists updated including Arizona MFD CPT and HCPCS Policy, Codes Restricting Modifiers LT and RT, HCPCS and CPT MFD lists; history entries to 8/4/2022 archived.

10/11/2024Application and attachment updates

Application section updated and attachments (CPT, HCPCS, Arizona lists) updated; history entries prior to 10/11/2022 archived.

10/20/2024State exception update

State Exceptions section: Indiana updated; attachment lists updated.

11/03/2024Attachment update

Attachment Section: Maximum Frequency Per (MFD) HCPCS Policy List and Arizona MFD CPT and HCPCS Policy list updated; history entries to 11/03/2022 archived.

12/08/2024State and attachment updates

State Exceptions section: New Mexico updated; Arizona MFD CPT and HCPCS Policy list updated; history entries to 12/08/2022 archived.

12/15/2024Attachment update

Attachment Section: Arizona MFD CPT and HCPCS Policy list updated.

1/01/2025Attachment updates

Attachment Section: Maximum Frequency Per (MFD) HCPCS Policy List; MFD CPT Code Policy List; Codes Restricting Modifiers LT and RT Policy List updated; history entries to 1/01/2023 archived.

1/12/2025Attachment update

Attachment Section: Arizona MFD CPT and HCPCS Policy list updated.

1/19/2025Attachment update

Attachment Section: Arizona MFD CPT and HCPCS Policy list updated; history entries prior to 1/19/2023 archived.

2/09/2025State exception update

State Exceptions section: North Carolina updated; history entries prior to 2/09/2023 archived.

2/16/2025State exception update

State Exceptions section: Wisconsin updated.

3/09/2025Attachment and state updates

Attachment Section: Arizona MFD CPT and HCPCS Policy list updated; State Exceptions section: New Mexico, North Carolina and Minnesota updated; history entries prior to 3/09/2023 archived.

3/16/2025Attachment update

Attachment Section: Arizona MFD CPT and HCPCS Policy list updated.

3/30/2025Attachment and state updates

State Exceptions section: Indiana and Wisconsin updated; attachments including HCPCS, CPT and Codes Restricting Modifiers LT and RT updated; history entries prior to 3/30/2023 archived.

4/04/2025State exception update

State Exceptions section: New Jersey updated; history entries prior to 4/04/2023 archived.

4/13/2025State and attachment updates

State Exceptions section: North Carolina, Rhode Island and New Mexico updated; attachments including Missouri and Arizona MFD lists updated.

4/27/2025State exception update

State Exceptions section: New Jersey updated; Pennsylvania updated.

5/11/2025Attachment and state updates

State Exceptions section: Indiana and Ohio updated; Attachment Section: Arizona MFD CPT and HCPCS Policy list updated; history entries to 5/11/2023 archived.

5/18/2025Attachment update

Attachment Section: Maximum Frequency Per (MFD) HCPCS Policy List updated.

5/25/2025State exception update

State Exceptions section: Michigan added and Kentucky updated; history entries prior to 5/25/2023 archived.

6/08/2025State and attachment updates

State Exceptions section: Pennsylvania updated; Attachment Section: Arizona MFD CPT and HCPCS Policy list updated.

6/29/2025Attachment and state updates

State Exceptions section: North Carolina updated; Attachment Section: Arizona, HCPCS, CPT and Codes Restricting Modifiers LT and RT lists updated; history entries to 6/29/2023 archived.

7/13/2025State exception update

State Exceptions section: California removed; history entries prior to 7/13/2023 archived.

7/20/2025State and attachment updates

State Exceptions section: Idaho added; Attachment Section: Arizona MFD CPT and HCPCS Policy list updated.

8/10/2025Attachment and verbiage update

Attachment Section: Maximum Frequency Per (MFD) HCPCS Policy List and CPT Code Policy List updated; verbiage updated; history entries to 8/10/2023 archived.

8/17/2025State and attachment updates

State Exceptions section: Texas updated; Attachment Section: Arizona MFD CPT and HCPCS Policy list updated; history entries to 8/17/2023 archived.

8/24/2025State exception update

State Exceptions section: Colorado updated.

9/07/2025State exception update

State Exceptions section: Colorado and Texas updated; history entries prior to 9/07/2023 archived.

9/21/2025Attachment and state updates

State Exceptions section: New Jersey, Idaho and Colorado updated; Attachment Section: Arizona MFD list, HCPCS list, CPT list and Codes Restricting Modifiers LT and RT updated; history entries prior to 9/21/2023 archived.

10/05/2025Attachment and state updates

State Exceptions section: Texas updated; Attachment Section: Arizona MFD CPT and HCPCS Policy list updated; history entries to 10/05/2023 archived.

10/12/2025State exception update

State Exceptions section: Rhode Island updated; history entries prior to 10/12/2023 archived.

10/19/2025Attachment and state updates

State Exceptions section: Colorado updated; Attachment Section: MFD HCPCS and CPT lists updated; history entries prior to 10/19/2023 archived.

10/26/2025Attachment and state updatesLatest

State Exceptions section: Virginia updated; Attachment Section: Arizona MFD CPT and HCPCS Policy list updated; history entries to 10/26/2023 archived.