CurrentUnitedHealthcarePolicy N/A

Modifier SU (Procedure performed in physician's office) — Reimbursement Policy

This reimbursement policy governs UnitedHealthcare Community Plan's treatment of claims appended with HCPCS modifier SU for services billed on CMS-1500 (and when specified, UB04) and applies to Community Plan Medicaid products and all network and non-network physicians and other qualified health care professionals.

Policy Summary

PayerUnitedHealthcare

PolicyModifier SU (Procedure performed in physician's office) — Reimbursement Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDo not expect separate reimbursement for services appended with modifier SU when billed in an office place of service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Community Plan Medicaidproduct applicability

Not reimbursedoffice POS stance

CA, PA, TX, WAstate exceptions

CMS-1500claim form scope

Reimbursement Position

Policy Summary

PayerUnitedHealthcare

PolicyModifier SU (Procedure performed in physician's office) — Reimbursement Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDo not expect separate reimbursement for services appended with modifier SU when billed in an office place of service.

SourceLink

On This Page

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.

Modifier SU appended to a service billed in an office place of service is not reimbursed because practice expense is included in the physician's RVU.

If charges for the use of facility/equipment (modifier SU) are submitted by a different provider than the physician performing the procedure, those charges will not be separately reimbursed.

State exceptions

California — Modifier SU is not an approved modifier for CA Medicaid (no reimbursement).
Pennsylvania — SU modifier is allowed when reported with CPT code 55250 in POS 11.
Texas — SU modifier is allowed on CPT codes 86001, 86003, and 86005.
Washington — Washington reimburses a facility fee when services are performed in licensed birthing centers with a Core Provider Agreement; facility payments are billed with SU by the midwife who must reimburse the birthing center; when SU is attached to the delivery code it reports use of the provider's facility or equipment only.

Modifier and Place of Service Coding

Modifier SUHCPCSNot Covered

SU	HCPCS modifier SU — Procedure performed in physician's office (to denote use of facility and equipment)

Place of Service

Place of Service (POS)Office — POS 11: modifier SU is not reimbursed because practice expense (facility/equipment) is included in the physician's RVU; state-specific exceptions may apply (CA, PA, TX, WA).

Applicable claim formsServices billed on CMS-1500 (and electronic equivalent); when specified, UB04 applies.

ScopeApplies to UnitedHealthcare Community Plan Medicaid products for all network and non-network physicians and qualified health care professionals.

Billing and Submission Responsibilities

Documentation Required

Provider claim submission responsibility

Submit accurate claims using CPT/HCPCS/CMS coding guidelines and the CMS-1500 (or UB04 when specified). Follow state and contract-specific rules and benefit design that may modify this policy; UnitedHealthcare Community Plan may use discretion in applying the policy and may update it by publishing a new version.

Use the code or codes that correctly describe the health care services provided per CPT, CMS or other coding guidelines.
Apply state regulatory requirements, provider contract terms, and enrollee benefit coverage documents that may supplement or supersede this policy.
Recognize that implementation may vary across claims processing systems and the policy may be updated by UnitedHealthcare Community Plan.

Billing Rule

Prior authorization / payment expectation

Do not expect separate reimbursement for services appended with HCPCS modifier SU when billed in an office place of service; practice expense is included in the physician's RVU and SU-appended charges will not be separately reimbursed, including when submitted by a different provider.

Modifier SU appended to a service billed in an office POS is not reimbursed because office practice expenses are included in the physician's RVU.
If charges associated with modifier SU are submitted by a different provider than the physician performing the procedure, they will not be considered for separate reimbursement.
State-specific exceptions exist (e.g., CA, PA, TX, WA) — verify state rules before billing.

Key Terms

Relative Value Units (RVU)

DefinitionRelative Value Units (RVU) — the assigned unit value of a particular CPT or HCPCS code; associated RVU includes practice expense components (costs of running an office such as rent, equipment, supplies, and non-physician staff).

Why it mattersPractice expense RVUs include facility and equipment costs, so separate reimbursement for modifier SU in the office is not allowed.

Policy alignmentUnitedHealthcare Community Plan follows CMS RVU methodology when determining non‑reimbursement for SU in POS 11.

Modifier SU (definition and payment rationale)

Modifier SU — definitionHCPCS modifier SU: Procedure performed in physician's office to denote use of facility and equipment.

Payment rationaleNot payable when appended to services billed in an office (POS 11) because CMS-established practice expense RVUs include the costs of running an office, so separate reimbursement for SU is not allowed.

When charges by another providerIf charges for SU are submitted by a different provider than the physician performing the procedure, those charges will not be considered for separate reimbursement.

State exceptionsState-specific exceptions exist (examples: CA — SU not approved for CA Medicaid; PA — allowed with CPT 55250 in POS 11; TX — allowed on CPT 86001, 86003, 86005; WA — reimburses facility fee for licensed birthing centers under specific agreement).