Modifier Reference Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

According to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. It may also provide more information about a service such as it was performed more than once, unusual events occurred, or it was performed by more than one physician and/or in more than one location. This document is a reference tool to guide readers to reimbursement policies in which modifiers are addressed. For complete information, please refer to the specific reimbursement policy that pertains to your coding situation.

For information regarding the appropriate use of modifiers with individual CPT and HCPCS procedure codes refer to the Procedure to Modifier Policy.

Note: The lists below represent modifiers that are addressed in UnitedHealthcare reimbursement policies. It is not an all-inclusive list of CPT and HCPCS modifiers.

Policy Codes

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  • 00100
  • 01999
* COMM-Modifier-Reference-Policy.pdf
Click to Download: Modifier Reference Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans

Questions and Answers

Q: How are claims reimbursed for an Ambulatory Surgical Center when submitted on a 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form with an SG modifier?

A: Services reported on a CMS 1500 form with an SG modifier are not treated as professional claims. The SG modifier indicates facility services and the claim is treated as a facility claim and is not subject to UnitedHealthcare’s reimbursement policies.