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REIMBURSEMENT POLICY
UB-04 Policy Number 2019F7015
Proprietary information of UnitedHealthcare Community Plan. Copyright 2019 UnitedHealthcare Services, Inc. 2019F7015
Revenue Codes Requiring Procedure Code Policy, Facility
IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the facility or other provider contracts, the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Application
This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the UB-04 form or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network facilities including, but not limited to, non-network authorized and percent of charge contract facilities.
Policy
Overview
This policy describes revenue codes that require procedure codes based on National Uniform Billing Committee (NUBC) guidelines.
Reimbursement Guidelines
Per NUBC, outpatient UB-04 claims must be billed with both a revenue code and a CPT or HCPCS code. A revenue code must be assigned for each line item. If multiple CPT or HCPCS are necessary to reflect multiple, distinct, or independent visits with the same revenue code, repeat the revenue code as required. Absence of a CPT or HCPCs code for any revenue code not listed on this policy may affect claim payment or result in a claim denial. Revenue codes exempt from this requirement are listed in the Specific Lists Section This policy applies to all outpatient claims except for the following bill types:
Skilled Nursing (23X) Home Health (33X)
Religious Non Medical Healthcare (43X) Rural Health Care Clinic (71X)
REIMBURSEMENT POLICY
UB-04 Policy Number 2019F7015
Proprietary information of UnitedHealthcare Community Plan. Copyright 2019 UnitedHealthcare Services, Inc. 2019F7015
Hospital based Clinic (72X)
Free standing Clinic (73X) Federally Qualified Health Center Clinic (77X) Hospice (81X, 82X) Critical Access Hospital (85X)
State Exceptions
Florida Florida Medicaid has a custom list of revenue codes that require a procedure code
Hawaii Revenue code 0912 is allowed to be billed without a procedure code
Iowa Hospice bill types and revenue codes 0651, 0652, 0655, 0656, 0657, and 0658 are exempt from this requirement
Maryland Maryland Medicaid has a custom list of revenue codes that require a procedure code
Massachusetts Revenue code 0912 is allowed to be billed without a procedure code
Texas Texas Medicaid has a custom list of revenue codes that require a procedure code
Virginia Hospice bill types are exempt from this requirement
Wisconsin Wisconsin has a custom list of codes that are exempt from requiring a procedure code
State Specific Lists: Please right-click on the icon to open the file.
UnitedHealthcare Community Plan Revenue Codes Exempt from the Procedure Codes Requirement
List of revenue codes that are EXEMPT from the procedure code
Florida Medicaid Specific Revenue Codes
List of revenue codes that require a procedure code
Maryland Medicaid Specific Revenue Codes
List of revenue codes that require a procedure code
Texas Medicaid Specific Revenue Codes
List of revenue codes that require a procedure code
Wisconsin Medicaid Specific Revenue Codes
List of revenue codes that are EXEMPT from the procedure code
Resources
Individual state Medicaid regulations, manuals & fee schedules Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets
Revenue Code Description
250 PHARMACY
251 DRUGS/GENERIC
252 DRUGS/NONGENERIC
254 DRUGS/INCIDENT ODX
255 DRUGS/INCIDENT RAD
257 DRUGS/NONPSCRPT
258 IV SOLUTIONS
259 DRUGS/OTHER
260 IV THERAPY GENERAL
261 IV THER/INFSN PUMP
262 IV THER/PHARM/SVC
263 IV THER/DRUG SUPPLY/DELV
264 IV THER/SUPPLIES
269 IV THERAPY/OTHER
270 MED-SUR SUPPLIES
271 NONSTER SUPPLY
272 STERILE SUPPLY
273 TAKEHOME SUPPLY
275 PACE MAKER
276 INTR OC LENS
278 SUPPLY/IMPLANTS
279 SUPPLY/OTHER
280 ONCOLOGY GENERAL
289 ONCOLOGY OTHER
343 NUC MED/DX RADIOPHARM
344 NUC MED/RX RADIOPHARM
370 ANESTHESIA GENERAL
371 ANESTHE/INCIDENT RAD
372 ANESTHE/INCDNT OTHER DX
379 ANESTHE/OTHER
390 BLOOD/STOR GENERAL
392 BLOOD/STORAGE
399 BLOOD/OTHER STOR
500 OUTPATIENT SVS GENERAL
509 OUTPATATIENT/OTHER
521 RURAL/'CLINIC
522 RURAL/'HOME
524 FR/STND RURAL/SNF
525 FR/STND RURDL/SNF/NF/ICF
527 FR/STND RURAL HOME
528 FR/STND RURAL OTHER
583 VISIT/HOME HLTH UNASSGND
621 MED-SUR SUPP/INCDNT RAD
2019A Revenue Codes Exempt from
Procedure Code Requirement
622 MED-SUR SUPP/INCDNT ODX
623 SURG DRESSING
624 FDA INVEST DEVICE
630 DRUGS RESERVED
631 DRUG/SINGLE
632 DRUG/MULT
633 DRUGS/RSTR
637 DRUG/SELF-ADMIN
660 RESPITE/CARE GENERAL
661 RESPITE/SKILLED NURSE
662 RESPITE/HMEAID/HMEMKR
663 RESPITE/UNASSIGNED
669 RESPITE/OTHER
681 TRAUMA LEVEL I
682 TRAUMA LEVEL II
683 TRAUMA LEVEL III
684 TRAUMA LEVEL IV
689 TRAUMA OTHER
700 CAST ROOM GENERAL
710 RECOVERY ROOM GENERAL
720 DELIVEROOM/LABOR
721 LABOR
732 TELEMETRY
762 OBSERVATION RM
801 DIALY/INPT
802 DIALY/INPT/PER
803 DIALY/INPT/CAPD
804 DIALY/INPT/CCPD
809 DIALY/INPT/OTHER
810 ORGAN ACQUISIT GENERAL
815 ALOGNC STM CELL AQ. SVCS
819 OTHER DONOR
821 HEMO/COMPOSITE
824 HEMO/HOME/100%
825 HEMO/HOME/SUPSERV
829 HEMO/HOME/OTHER
860 MEG GENERAL
861 MEG
905 INTENS OP TREAT/PSYCH
906 INTENS OP TREAT/CHEM DEP
907 COMM BEHAVIORAL HEALTH
931 MED REHAB/HALF DAY
932 MED REHAB/FULL DAY
940 OTHER RX SVS GENERAL
942 EDUC/TRAINING
943 CARDIAC REHAB
948 PULMONARY REHABILITATION
990 PT CONVENIENCE GENERAL
991 CAFETERIA
992 LINEN
993 TELEPHONE
994 TV/RADIO
995 NONPT ROOM RENT
996 LATE DISCHARGE
997 ADMIT KITS
998 BARBER/BEAUTY
999 PT CONVENCE/OTHER
1000 BH ACCOM GEN
1001 BH ACCOM RES PSYCH
1002 BH ACCOM RES CHEM/DEP
1003 BH ACCOM GEN SUP LIVING
1004 BH ACCOM HALFWAY HOUSE
1005 BH ACCOM GROUP HOME
2100 ALT THER SVC GENERAL
2101 ALT THER SVC ACCUPUNCT
2102 ALT THER SVC ACCUPRESS
2103 ALT THER SVC MASSAGE
2104 ALT THER SVC REFLEXOLOGY
2105 ALT THER SVC BIOFEEDBACK
2106 ALT THER SVC HYPNOSIS
2109 ALT THER SVC OTHER
3101 ADULT MED/SOC HOURLY
3102 ADULT SOC HOURLY
3103 ADULT MED/SOC DAILY
3104 ADULT SOC DAILY
3105 ADULT FOSTER DAILY
3109 ADULT CARE OTHER
cwalto7File Attachment2019A UnitedHealthcare Community Plan Revenue Codes Exempt from Procedure Code Requirement v2.pdf
2019A Florida Medicaid Specific
Revenue Codes That Require a Procedure Code
0261
0274
0300
0301
0302
0303
0304
0305
0306
0307
0309
0310
0311
0312
0314
0319
0320
0321
0322
0323
0324
0329
0330
0331
0332
0333
0335
0339
0340
0341
0342
0343
0344
0349
0350
0351
0352
0359
0360
0361
0362
0367
0369
0371
0372
0374
0379
0380
0381
0382
0383
0384
0385
0386
0387
0389
0391
0400
0401
0402
0403
0404
0409
0410
0412
0413
0419
0420
0421
0422
0423
0424
0429
0430
0431
0432
0433
0434
0439
0440
0441
0442
0443
0444
0449
0450
0451
0452
0456
0459
0460
0469
0470
0471
0472
0479
0480
0481
0482
0483
0489
0490
0499
0510
0511
0512
0513
0514
0515
0516
0517
0519
0520
0521
0522
0523
0524
0525
0526
0527
0528
0529
0530
0531
0539
0540
0541
0542
0543
0544
0545
0546
0547
0548
0549
0561
0562
0570
0571
0572
0579
0590
0600
0601
0602
0603
0604
0609
0610
0611
0612
0614
0615
0616
0618
0619
0623
0634
0635
0636
0640
0641
0642
0643
0644
0645
0646
0647
0648
0649
0650
0651
0652
0655
0656
0657
0658
0659
0670
0671
0672
0679
0722
0723
0724
0730
0731
0732
0739
0740
0749
0750
0759
0760
0761
0769
0770
0771
0780
0790
0811
0812
0813
0814
0830
0831
0832
0833
0834
0835
0839
0840
0841
0842
0843
0844
0845
0849
0850
0851
0852
0853
0854
0855
0859
0880
0881
0882
0889
0900
0901
0902
0903
0904
0905
0906
0907
0911
0912
0913
0914
0915
0916
0917
0918
0919
0920
0921
0922
0923
0924
0925
0929
0940
0941
0943
0944
0945
0946
0947
0948
0949
0951
0952
cwalto7File Attachment2019A Florida Medicaid Specific Revenue Codes That Require a Procedure Code.pdf
2019A Maryland Medicaid Revenue Codes
that Require a Procedure Code
0360
0361
0490
0499
0750
0790
cwalto7File Attachment2019A Maryland Medicaid Specific Revenue Codes That Require a Procedure Code.pdf
2019A Texas Medicaid Specific Revenue
Codes That Require a Procedure Code
0220
0278
0279
0300
0301
0302
0303
0304
0305
0306
0307
0309
0310
0311
0312
0314
0319
0320
0321
0322
0323
0324
0329
0330
0331
0332
0333
0335
0339
0340
0341
0342
0349
0350
0351
0352
0359
0380
0381
0382
0383
0384
0385
0386
0387
0389
0400
0401
0402
0403
0404
0409
0419
0420
0421
0422
0423
0424
0429
0430
0431
0432
0433
0434
0439
0441
0442
0443
0444
0449
0450
0456
0459
0460
0469
0470
0471
0472
0479
0480
0481
0482
0483
0489
0550
0551
0552
0559
0560
0561
0562
0569
0570
0571
0572
0579
0580
0581
0582
0589
0610
0611
0612
0619
0730
0731
0732
0739
0740
0741
0770
0771
0779
0880
0920
0921
0922
0923
0924
0925
0929
0943
cwalto7File Attachment2019A Texas Medicaid Specific Revenue Codes That Require a Procedure Code.pdf
2019A Wisconsin Medicaid Revenue Codes EXEMPT
from Requiring a Procedure Code
0250
0251
0252
0253
0258
0270
0271
0272
0276
0278
0370
0500
0509
0521
0522
0524
0525
0527
0528
0583
0660
0661
0662
0663
0669
0710
0762
0907
0912
0913
0931
932
0948
0990
0991
0992
0993
0994
0995
0996
0997
0998
0999
1000
1001
1002
1003
1004
1005
2100
2101
2102
2103
2104
2105
2106
2109
3101
3102
3103
3104
3105
3109
cwalto7File Attachment2019A Wisconsin Medicaid Revenue Code EXEMPT from Requiring a Procedure Code.pdf
REIMBURSEMENT POLICY
UB-04 Policy Number 2019F7015
Proprietary information of UnitedHealthcare Community Plan. Copyright 2019 UnitedHealthcare Services, Inc. 2019F7015
National Uniform Billing Committee (NUBC)
History
5/28/2019 Title Section Changed. Removed RPOC reference State Exceptions Section: Removed exceptions for New Mexico, added exception for Maryland Attachment Section: Covered Codes List updated for Florida
1/16/2019 Attachments section, Revenue codes requiring HCPCs for Florida Medicaid updated.
4/1/2018 Policy Implemented by UnitedHealthcare Community & State
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