CurrentUnitedHealthcarePolicy N/A

Outpatient facility claim modifiers and reimbursement adjustments

Defines UnitedHealthcare's reimbursement treatment (reductions, denials, or informational handling) for specific modifiers appended to outpatient facility (UB-04) claims for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient facility claim modifiers and reimbursement adjustments

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDo not submit modifier 53 on facility claim lines; such lines will be denied and may be resubmitted with an appropriate modifier if applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15%CT non‑compliant reduction

7%→10%FX reduction (date-based)

7%→10%FY reduction (date-based)

DenialModifier 53 outcome

InformationalModifier 74 outcome

Modifier-specific reimbursement handling

Modifier-specific reimbursement criteria

UnitedHealthcare will apply reductions, denials, or informational handling to outpatient facility (UB‑04) claim lines appended with the following modifiers.

Modifier CT: When CT services are furnished on non‑NEMA XR‑29‑2013‑compliant equipment, the allowed amount will be reduced by 15%.

Modifier FX: Indicates an X‑ray performed using film. Allowed amount reduction: 7% for services provided prior to 2023‑01‑01; 10% for services provided on or after 2023‑01‑01.

Modifier FY: Indicates an X‑ray taken using computed radiography/cassette‑based imaging. Allowed amount reduction: 7% for services provided prior to 2023‑01‑01; 10% for services provided on or after 2023‑01‑01.

Modifier 52: Reduced service — when present on a facility claim line, the allowed amount will be reduced (amount not specified in this document).

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient facility claim modifiers and reimbursement adjustments

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDo not submit modifier 53 on facility claim lines; such lines will be denied and may be resubmitted with an appropriate modifier if applicable.

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.

Modifiers and coding details

Covered/modifier billing rulesmixed

52	Reduced services; allowed amount will be reduced when present.
73	Discontinued outpatient hospital/ASC procedure prior to administration of anesthesia; allowed amount reduction will be applied.
CT	Computed tomography services furnished on non‑NEMA XR-29-2013-compliant equipment; allowed amount reduced by 15%.
FX	X-ray performed using film; allowed amount reduced 7% for services prior to 2023-01-01 and 10% for services on or after 2023-01-01.
FY	X-ray using computed radiography/cassette-based imaging; allowed amount reduced 7% for services prior to 2023-01-01 and 10% for services on or after 2023-01-01.
74	Discontinued outpatient hospital/ASC procedure after administration of anesthesia; informational on facility claims — no reduction applied.

Denied on facility claimmixedNot Covered

53	Discontinued procedures; not appropriate on facility claim — claim line will be denied; provider may resubmit with an appropriate modifier if applicable.

FX/FY effective date threshold (inv-03)

FX/FY reduction rate7% for services provided prior to 2023-01-01; 10% for services provided on or after 2023-01-01

Effective date of changeJanuary 1, 2023 (rates change from 7% to 10%)

Applies toX‑ray services billed with modifier FX (film) or FY (computed radiography/cassette) on outpatient facility claims

Billing rules and provider responsibilities

Documentation Required

Submit accurate claims using appropriate CPT/CMS coding; UnitedHealthcare discretion

You are responsible for submitting accurate claims using the CPT/CMS codes and coding guidance that correctly describe the services provided. UnitedHealthcare may interpret and apply this reimbursement policy using reasonable discretion and other factors (for example, regulatory requirements, provider contracts, benefit design, or other policies) may affect reimbursement.

Denial Risk

Facility claim lines with modifier 53 will be denied; resubmit if applicable

Do not submit modifier 53 on an outpatient facility claim line — it is not appropriate and will result in denial. If modifier 53 is submitted and the line is denied, the provider may resubmit the claim line with an appropriate modifier where applicable.

Facility claim lines appended with modifier 53 will be denied.
Provider may resubmit the denied line with an appropriate modifier if applicable.

Modifier definitions

Modifier 52 (inv-06)

Modifier52

DefinitionReduced service

Reimbursement effectAllowed amount will be reduced when present on an outpatient facility claim line

Modifier 53 (inv-07)

Modifier53

DefinitionDiscontinued procedures

Facility claim handlingNot appropriate on facility claims; claim line will be denied and may be resubmitted with an appropriate modifier if applicable

Modifier 73 (inv-08)

Modifier73

DefinitionDiscontinued outpatient hospital/ASC procedure prior to administration of anesthesia

Reimbursement effectAllowed amount will be reduced when present on an outpatient facility claim line

Modifier 74 (inv-09)

Modifier74

DefinitionDiscontinued outpatient hospital/ASC procedure after administration of anesthesia

Facility claim handlingInformational on facility claims; no reduction in reimbursement will be applied

Modifier CT (inv-10)

ModifierCT

DefinitionComputed tomography services furnished on non‑NEMA XR-29-2013-compliant CT equipment

Reimbursement effectAllowed amount for these services will be reduced by 15%

Modifier FX (inv-11)

ModifierFX

DefinitionX‑ray performed using film

Reimbursement effectAllowed amount reduced 7% for services before 2023-01-01 and 10% for services on/after 2023-01-01

Modifier FY (inv-12)

ModifierFY

DefinitionX‑ray taken using computed radiography/cassette-based imaging

Reimbursement effectAllowed amount reduced 7% for services before 2023-01-01 and 10% for services on/after 2023-01-01