maximum frequency per day policy...2012/04/01 · reimbursing for obvious billing submission and...
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Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
Maximum Frequency Per Day Policy Type Reimbursement
Number 2013R0060B
Approved By Approval Date
United HealthCare Community & State Payment Policy Committee
12/10/2012
National Reimbursement Forum 5/9/2012
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 Planreimbursement 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 CMS 1500 forms and, when specified, to those 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 physician or other provider contracts, and/or the enrollee’s benefit coverage documents. 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. UnitedHealthcare Community Plan uses a customized version of the Ingenix Claims Editing System known as iCES Clearinghouse to process claims in accordance with UnitedHealthcare Community Plan reimbursement policies.
*CPT® is a registered trademark of the American Medical Association
Confidential and Proprietary, © UnitedHealthcare Community & State 2013
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
Table of Contents
Application
Policy Overview Reimbursement MUE Editing
MFD Determination Part I Part II
Reimbursement Modifiers
Anatomic Modifiers
State Specifics
Definitions
Questions and Answers
Attachments
Resources
History
Application
This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians and other health care professionals. This includes non-network authorized and percent of charge contract physicians and other health care professionals. Payment Policies for Medicare & Retirement, Employer & Individual, Florida Medicaid and Rhode Island Medicaid please use this link.
Policy
Overview The purpose of this policy is to ensure that UnitedHealthcare reimburses physicians and other health care professionals for the units billed without reimbursing for obvious billing submission and data entry errors. To do this, UnitedHealthcare has established maximum frequency per day (MFD) values, which are the highest number of units eligible for reimbursement of services on a single date of service. Reimbursement also may be subject to the application of other UnitedHealthcare Reimbursement policies such as "Laboratory Rebundling"
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or "Professional/Technical Component." This policy applies whether a physician or other health care professional submits one Current Procedural Terminology (CPT ®) or Healthcare Common Procedure Coding System (HCPCS) code with multiple units on a single claim line or multiple claim lines with one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted with multiple units. MFD values will be evaluated and/or updated quarterly to reflect new, changed, and deleted codes. Review of MFD values for existing CPT and HCPCS codes based on criteria within this policy will be completed annually. For the purpose of this policy, the same individual physician or other health care professional is the same individual rendering health care services reporting the same Federal Tax Identification number.
Reimbursement
MUE Editing
Section 6507 of the Affordable Care Act requires each State Medicaid program to implement compatible methodologies of the NCCI, to promote correct coding, and to control improper coding leading to inappropriate payment. Specifically, section 6507 of the Affordable Care Act amends section 1903(r) of the Social Security Act (the Act). Section 1903(r)(4) of the Act, as amended, required that CMS notify States by September 1, 2010, of the NCCI methodologies that are “compatible” with claims filed with Medicaid, in order to promote correct coding and to control improper coding leading to inappropriate payment of claims under Medicaid. States were required to incorporate these methodologies for Medicaid claims filed on or after October 1, 2010. The NCCI methodologies include both NCCI Procedure-to-Procedures (PTP) edits and Medically Unlikely Edits (MUEs). Medically Unlikely Edits (MUEs) define for many HCPCS / CPT codes the maximum allowable number of units of service by the same provider, for the same beneficiary, for the same date of service, on the same claim line. Reported units of service greater than the MUE value are unlikely to be correct (e.g., a claim for excision of more than one gallbladder or more than one pancreas). Billed claim lines with a unit-of-service value greater than the established MUE value for the HCPCS / CPT code are denied payment in their entirety. For additional information, see Q&A #14 and the CMS link below. CMS National Correct Coding Initiative (NCCI) Medicaid CMS National Correct Coding Initiative (NCCI) Medicare
MFD Determination
UnitedHealthcare Community Plan will follow the CMS MUE values before any other MFD criteria is applied. If there is not a CMS MUE value or the CMS MUE value is not exceeded, then the following criteria has been used to establish MFD values.
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Part I The following criteria are first used to determine the MFD values for codes to which these criteria are applicable:
The service is classified as bilateral (CMS Indicators 1 or 3) on the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (NPFS) or the term 'bilateral' is included in the code descriptor. For the majority of these codes, the MFD value is 1. There are some codes that describe more than one anatomical site or vertebral level that can be treated bilaterally where the MFD value may be more than 1.
The service is anatomically or clinically limited with regard to the number of times it may be performed, in which case the MFD value is established at that value.
The CPT or HCPCS code description/verbiage indicates the number of times the service can be performed, in which case the MFD value is set at that value.
CMS Durable Medical Equipment Regional Carrier (DME MAC) Local Coverage Determination (LCD) assigns an MFD value in which case the MFD value is set at that value.
Where the criteria above has not defined an MFD value, the CMS Medically Unlikely Edits (MUE) value, where available, will be utilized to establish an MFD value.
Where no other definitive value has been established based on the criteria above, drug HCPCS codes will have an MFD value of 999 which indicates they are exempt from the MFD policy.
Where no other definitive value has been established based on the criteria above, unlisted CPT and HCPCS codes will have an MFD value of 999 which indicates they are exempt from the MFD policy.
Where no other definitive value has been established based on the criteria above, new CPT codes released by the American Medical Association and new HCPCS codes released by CMS since the last MFD value update (not covered by any of the above criteria), will have an MFD value of 100.
Part II When none of the criteria listed in Part I apply to a code, data analysis is conducted to establish MFD values according to common billing patterns.
When a code has 50 or more claim occurrences in a data set, the MFD values are determined through claim data analysis and are set at the 100th percentile (i.e. the highest number of units billed for that CPT or HCPCS code in the data set). If the 100th percentile exceeds the 98th percentile by a factor of four, the MFD value will be set at the 98th percentile.
When a code has less than 50 claim occurrences in a data set, the MFD values will be set at the default of 100 until the next annual analysis.
In any case where, in UnitedHealthcare Community Plan's judgment, the 98th percentile does not account for the clinical circumstances of the services billed, the MFD for a code may be increased so as to capture only obvious billing submission and data entry errors.
The "MFD CPT Values" and the "MFD HCPCS Values" lists below contain the most current MFD values.
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2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
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Reimbursement
The MFD values apply whether a physician or other health care professional submits one CPT or HCPCS code with multiple units on a single claim line or multiple claim lines with one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted with multiple units. However, when reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim line may be classified as a duplicate service and/or subject to additional UnitedHealthcare Community Plan reimbursement policies such as "Laboratory Rebundling" or "Professional/Technical Component."
Services provided are reimbursable services up to and including the MFD value for an individual CPT or HCPCS code. In some instances, a modifier may be necessary for correct coding and corresponding reimbursement purposes. See Q & A #3, 4 and 5.
Bilateral payment via the use of modifiers LT or RT is inappropriate for procedures, services, and supplies where the concept of laterality does not apply. UnitedHealthcare Community Plan will pay up to the maximum frequency per day value for codes with "bilateral" or "unilateral or bilateral" in description or for codes where the concept of laterality does not apply, whether submitted with or without modifiers LT and/or RT by the same individual physician or other healthcare professional on the same date of service for the same member. Use of modifiers LT and/or RT on the codes identified in the "Codes Restricting Modifiers LT and RT" list will be considered informational only.
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
There may be situations where a physician or other healthcare professional reports units accurately and those units exceed the established MFD value. In such cases, UnitedHealthcare Community Plan will consider additional reimbursement if reported with an appropriate modifier such as modifier 59, 76, or 91. Medical records are not required to be submitted with the claim when modifiers 59, 76, or 91 are appropriately reported. Documentation within the medical record should reflect the number of units being reported and should support the use of the modifier.
Modifiers
Modifier Modifier Description
59
Distinct Procedural Service Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different
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procedure or surgery, different size or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25.
76
Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.
Note: This modifier should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25. It is also inappropriate to use modifier 76 to indicate repeat laboratory services. Modifiers 59 or 91 should be used to indicate repeat or distinct laboratory services, as appropriate according to the AMA and CMS. Separate consideration for reimbursement will not be given to laboratory codes reported with modifier 76.
91
Repeat Clinical Diagnostic Laboratory Test In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
Anatomic Modifiers
Modifier Modifier Description Modifier Modifier Description
E1 Upper left, eyelid E3 Upper right, eyelid
E2 Lower left, eyelid E4 Lower right, eyelid
F1 Left hand, second digit F5 Right hand, thumb
F2 Left hand, third digit F6 Right hand, second digit
F3 Left hand, fourth digit F7 Right hand, third digit
F4 Left hand, fifth digit F8 Right hand, fourth digit
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FA Left hand, thumb F9 Right hand, fifth digit
T1 Left foot, second digit T5 Right foot, great toe
T2 Left foot, third digit T6 Right foot, second digit
T3 Left foot, fourth digit T7 Right foot, third digit
T4 Left foot, fifth digit T8 Right foot, fourth digit
TA Left foot, great toe T9 Right foot, fifth digit
LC Left circumflex coronary artery RC Right coronary artery
LD Left anterior descending coronary artery
RI Ramus intermedius coronary artery
LM Left main coronary artery RT Right side
LT Left side
State Exceptions
Arizona Arizona Health Care Cost Containment System (AHCCCS) publishes a unit limit list specific to Arizona Medicaid. Arizona does not exclude network home health services and supplies/home health agencies; anesthesia management; ambulance services
Florida Florida has an exception from CMS for CPT codes 92507 & 92508. Florida reimburses speech therapy in 15 minute time increments and allows a maximum of 4 units for each code.
Kansas Kansas has an exception from CMS for CPT codes 90472 & 90474 to be exempt from MUE edit limits
Texas Code S5101 may have 2 units reimbursed Multiple units allowed for codes 90460, 90461, 90472 & 90474 Multiple units allowed for code 92507 when billed on a facility claim form
Wisconsin Wisconsin Department of Health Services publish separate unit limits specific to Wisconsin Medicaid for specific physical, occupational, and speech therapy services.
Definitions
Maximum Frequency Per Day Value (MFD)
The maximum frequency per day (MFD) value is the number of units established by UnitedHealthcare Community Plan that are eligible for reimbursement of services on a single date of service, but may be subject to the application of other UnitedHealthcare Community Plan Reimbursement policies such as "Laboratory Rebundling" or
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"Professional/Technical Component."
Same Individual Physician or Other Health Care Professional
The same individual rendering health care services reporting the same Federal Tax Identification number.
Unit/Units The number of times a service with the same CPT or HCPCS code is provided per day by the same physician or non-physician.
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Questions and Answers
Q1: Why do you exclude network home health services and supplies/home health agencies, anesthesia management, and ambulance providers from this policy?
A1: There are many contracts specific to these physicians and other health care professionals that permit codes to be used in a different manner than intended by CPT and HCPCS, which make the application of this policy unworkable. Billing practices may also dictate that the units field is used to report something other than how many times a service was performed (i.e. mileage), which again may make the application of this policy unworkable. These providers were excluded until contract language and/or billing practices can be reviewed and changed.
Q2: When the frequency of a billed service on a date of service is greater than the established MFD value, will there be additional reimbursement?
A2: When a physician or other healthcare professional reports units accurately, yet those units exceed the established MFD value, an appropriate modifier such as 59, 76, or 91 may be utilized. The MFD value is a threshold set solely to avoid overpayment due to billing and data entry errors. UnitedHealthcare Community Plan intends to reimburse all services performed and reported with proper coding in accordance with its reimbursement policies and benefit or provider contracts. Medical records do not need to be submitted for the purposes of this policy, unless the processed claim is being submitted on appeal. When reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim line may be classified as a duplicate service and subject to additional UnitedHealthcare Community Plan reimbursement policies such as "Laboratory Rebundling" or "Professional/Technical Component."
Q3: Why has UnitedHealthcare Community Plan set the MFD value at "1" for bilateral procedures?
A3: UnitedHealthcare Community Plan has set the MFD value for most bilateral procedures at "1." The preferred method of billing a bilateral eligible procedure is with "1" unit on one claim line with modifier 50. Modifier 50 indicates that one procedure was performed bilaterally. Bilateral eligible procedures may also be billed on two lines with "1" unit each and modifiers RT and LT. There are some codes that describe more than one anatomical site or vertebral level that can be treated bilaterally where the MFD value may be more than 1.
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Q4: Would the MFD value for bilateral procedures remain at "1" unit if it is possible to perform these procedures more than once per day?
A4: If the bilateral procedure is provided more than once per day, modifiers 59 or 76 may be appropriate to bill depending on the circumstance. Additional reimbursement will be considered with the use of these modifiers.
Q5: Would the MFD value for hand or foot bilateral procedures remain at "1" unit if it is possible to perform the procedure on multiple digits such as fingers or toes?
A5: The MFD value would remain at 1 unit, however, HCPCS modifiers FA or F1-9 may be used to report specific fingers; TA or T1-9 may be used to report specific toes.
Q6: What is an example of a code that is limited because of anatomical or clinical reasons?
A6: CPT code 44950- Appendectomy would be set at the MFD value of 1 unit because a person only has one appendix.
Q7: How should 90460 and/or 90461 be reported when multiple immunizations with face-to-face counseling are performed on the same date of service? For example, if the physician or other health care professional administers immunizations for a 2-month-old infant on the same date of service according to the current immunization schedule, how should the following immunizations be reported?
Immunization Components CPT Code
DtaP intramuscular administration 3 90460
90461 x 2
Rotavirus oral administration 1 90460
Hepatitis B and Hemophilus influenza b intramuscular administration
2 90460
90461
Poliovirus intramuscular administration
1 90460
Pneumococcal conjugate vaccine 1 90460
A7: Coding practices may vary by physician or other healthcare professional offices. It is appropriate to report the immunization administration of the first and additional vaccine/toxoid component with face-to-face counseling on one line with multiple units and a link to all associated ICD-9-CM codes or report each component on a separate line. In the example above, the claim could be reported as 90460 with 5 units on one line and 90461 with 3 units on a separate line with the associated ICD-9-CM diagnoses linked to each line. It is also appropriate to report the administration of each vaccine component on separate lines; e.g. reporting 5 lines for 90460 with 1 unit each and 3 lines for 90461 with 1 unit each. However, when reporting the same CPT or HCPCS code on multiple lines and/or on separate
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claims, the additional claim line(s) reported with the same procedure code may be denied as a duplicate service.
Q8: How are MFD values for immunization administration CPT codes 90472, and 90474 determined? A8: UnitedHealthcare Community Plan follows the recommendations from the Center for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) to set the MFD value for additional immunization administration codes.
Q9: What is an example of a CPT or HCPCS codes where the "description/verbiage" clearly indicates the number of units that can be performed? A9: Code 11100-Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion. Because the code includes "single lesion", it should only be billed with one (1) unit.
Q10: Why are unlisted CPT and HCPCS codes set at an MFD value of 999? A10: Unlisted CPT and HCPCS codes are set at an MFD value of 999 because unlisted codes are individually reviewed. The review of documentation will identify the accurate number of services performed for the unlisted code.
Q11: Why are many new CPT and HCPCS codes set at an MFD value of 100? A11: There is no data or previous claim history for new codes. Setting the MFD value at 100 allows claims to be processed and prevents most overpayments from occurring due to billing errors and data entry errors. Once claims data is available on a code, the MFD value will be established.
Q12: What is an example of determining the MFD value at the 100th percentile unless the 100th percentile exceeds the 98th percentile by greater than a factor of 4?
A12: Statistical calculation: (A) x 4 = (C); if (B) is greater than (C), then the 98th percentile is set for the MFD value. If (B) is less than or equal to (C), then the 100th percentile is set for the MFD value. Here are two examples of determining MFD values based on a factor of 4.
Code (A) Units @
98th (B) Units @
100th (C) Factor of 4 Set MFD at:
81000 1 10 4 1
20610 1 4 4 4
Q13: What is an example of a clinical circumstance where UnitedHealthcare Community Plan would assign a specific MFD value?
A13: 71020-Radiological examination, chest; single view, frontal. According to standard criteria, the data showed the 98th percentile at 1 unit and the 100th percentile at 10 units. The statistical calculation would have set the MFD value at 1. UnitedHealthcare Community Plan was made aware of scenarios where there are more frequent chest x-rays required in a hospital setting on one date of service. Based on assessment of the circumstance, UnitedHealthcare Community Plan increased the MFD value to four (4).
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Q14: “Upon analysis by States, what if an edit is found to be in conflict with a State law or regulation, but is currently included within an NCCI methodology?” A14: “CMS allows States to consider edits on an individual State-by-State basis. If a State determines that some portion of the 1.3 million edits in the Medicaid NCCI methodologies conflict with one or more State laws, regulations, administrative rules, or payment policies, CMS may allow a State to deactivate the conflicting edit(s). States are not afforded the flexibility to deactivate edits after March 31, 2011, because of a lack of operational readiness. The first time that a State requests CMS approval for the State to deactivate a Medicaid NCCI edit, the State must submit to its CMS Regional Office a Medicaid NCCI Advance Planning Document (APD) with sufficient primary source documentation of the State law, regulation, administrative rule, or payment policy the edit conflicts with. Subsequent requests do not require an APD.” From: Questions and Answers Section 6507 of the Affordable Care Act, NCCI Methodologies August 2010 Updated January 2012
Attachments
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Designates the maximum frequency per day value assignments for CPT codes.
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Designates the maximum frequency per day value assignments for HCPCS codes.
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
Codes that allow up to the MFD limit that have "bilateral" or "unilateral or bilateral" in the description or the where concept of laterality does not apply.
Resources
Individual state Medicaid regulations, manuals & fee schedules American Medical Association, Current Procedural Terminology ( CPT® ) Professional Edition and associated publications and services Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices
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Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets
History
2/16/2013 Policy Change: Anatomic Modifiers section updated State exceptions section updated: Kansas information added
1/1/2013 Annual Policy Version Change State Specific Section: SC removed; TX added Policy Change: Policy Overview section updated Policy List Change: MFD CPT and HCPCS policy lists updated; Codes Restricting Modifiers LT and RT lists updated History Section: Entries prior to 11/22/2010 archived
12/10/12 Annual renewal of policy approved
11/18/2012 Policy List Change: MFD CPT and HCPCS policy lists; Codes Restricting Modifiers LT and RT list updated.
9/2/2012 State exception section updated: Florida information added.
8/19/2012 Policy List Change: MFD CPT and HCPCS policy lists; Codes Restricting Modifiers LT and RT list updated. Policy Verbiage Change: Reimbursement section, MUE section added Q&A #14 added
8/12/2012 Policy Change: State Exceptions section updated, South Carolina and Wisconsin added.
6/17/2012 Policy List Change: MFD CPT and HCPCS policy lists updated.
4/1/2012 Policy Change: Reimbursement Guidelines show title change for DMERC Policy List Change: MFD CPT and HCPCS policy lists; and Codes Restricting Modifiers LT and RT updated. History prior to 11/16/2009 archived
1/1/2012 Annual Policy Version Change Policy List Change: MFD CPT and HCPCS policy list updated; Codes Restricting Modifiers LT and RT updated
11/20/2011 Policy List Change: MFD CPT and HCPCS policy list updated; Codes Restricting Modifiers LT and RT updated.
10/10/2011 Update Arizona state specifics
8/15/2011 Policy Change: Overview section updated. MFD Determination section updated. Modifier section updated. Attachment section updated. Policy List Change: MFD CPT and HCPCS policy lists updated; Codes Restricting Modifiers LT and RT updated.
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5/23/2011 Annual renewal of policy approved
5/16/2011 Policy List Change: MFD CPT and HCPCS policy lists updated; Codes Restricting Modifiers LT and RT updated.
2/14/2011 Policy Change: Reimbursement section updated. Policy Q & A Change: Q & A #7 added. Subsequent Q & As renumbered.
1/5/2011 Policy List Change: HCPCS and Codes Restricting Modifiers LT and RT updated
1/3/2011 Annual Policy Version Change Policy Change: Overview, Reimbursement, Definitions, and Modifier sections updated Policy Q&A Change: Q&A #2 and 7 updated. Policy List Change: MFD CPT and HCPCS policy lists updated.
11/22/2010 Policy List Change: MFD CPT and HCPCS policy lists updated; Codes Restricting Modifiers LT and RT updated.
1/6/2006 Policy implemented by UnitedHealthcare Community & State
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2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value0019T 1 26706 1 35881 1 54130 1 73070 1 86900 1
0042T 1 26715 1 35883 1 54135 1 73080 1 86901 1
0051T 1 26720 1 35884 1 54150 1 73085 1 86902 27
0052T 1 26725 1 35901 1 54160 1 73090 1 86904 2
0053T 1 26727 1 35903 2 54161 1 73092 1 86905 11
0054T 2 26735 1 35905 1 54162 1 73100 1 86906 1
0055T 2 26740 3 35907 1 54163 1 73110 1 86910 100
0058T 1 26742 3 36000 1 54164 1 73115 1 86911 100
0059T 1 26746 3 36002 1 54200 1 73120 1 86920 8
0071T 1 26750 1 36005 1 54205 1 73130 1 86921 2
0072T 1 26755 1 36010 1 54220 1 73140 1 86922 8
0073T 2 26756 1 36011 1 54230 1 73200 1 86923 9
0075T 1 26765 1 36012 1 54231 1 73201 1 86927 2
0076T 2 26770 2 36013 2 54235 1 73202 1 86930 2
0078T 1 26775 2 36014 1 54240 1 73206 2 86931 100
0079T 4 26776 2 36015 1 54250 1 73218 1 86932 2
0080T 1 26785 2 36100 1 54300 1 73219 1 86940 1
0081T 4 26820 1 36120 2 54304 1 73220 1 86941 1
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2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value0085T 100 26841 1 36140 4 54308 1 73221 1 86945 3
0092T 1 26842 1 36147 1 54312 1 73222 1 86950 1
0095T 1 26843 1 36148 3 54316 1 73223 1 86960 3
0098T 1 26844 1 36160 2 54318 1 73225 1 86965 1
0099T 2 26850 1 36200 1 54322 1 73500 1 86970 1
0100T 2 26852 1 36215 4 54324 1 73510 1 86971 9
0101T 1 26860 1 36216 3 54326 1 73520 1 86972 4
0102T 2 26861 2 36217 2 54328 1 73525 1 86975 2
0103T 1 26862 1 36218 4 54332 1 73530 1 86976 2
0106T 4 26863 2 36221 1 54336 1 73540 1 86977 2
0107T 4 26910 1 36222 1 54340 1 73550 1 86978 1
0108T 4 26951 1 36223 1 54344 1 73560 1 86985 1
0109T 4 26952 1 36224 1 54348 1 73562 1 86999 999
0110T 4 26989 999 36225 1 54352 1 73564 1 87001 1
0111T 1 26990 2 36226 1 54360 1 73565 1 87003 1
0123T 2 26991 2 36227 1 54380 1 73580 1 87015 1
0124T 2 26992 1 36228 4 54385 1 73590 1 87040 1
0126T 1 27000 1 36245 4 54390 1 73592 1 87045 1
0159T 2 27001 1 36246 3 54400 1 73600 1 87046 1
0163T 4 27003 1 36247 1 54401 1 73610 1 87070 1
0164T 4 27005 1 36248 4 54405 1 73615 1 87071 1
0165T 4 27006 1 36251 1 54406 1 73620 1 87073 1
0169T 1 27025 1 36252 1 54408 1 73630 1 87075 1
0171T 1 27027 1 36253 1 54410 1 73650 1 87076 1
0172T 4 27030 1 36254 1 54411 1 73660 1 87077 1
0174T 1 27033 1 36260 1 54415 1 73700 1 87081 1
0175T 1 27035 1 36261 1 54416 1 73701 1 87084 1
0178T 1 27036 1 36262 1 54417 1 73702 1 87086 1
0179T 1 27040 1 36299 999 54420 1 73706 1 87088 1
0180T 1 27041 1 36400 1 54430 1 73718 1 87101 1
0181T 1 27043 3 36405 1 54435 1 73719 1 87102 1
0182T 3 27045 3 36406 1 54440 1 73720 1 87103 1
0183T 1 27047 1 36410 3 54450 1 73721 1 87106 1
0184T 1 27048 1 36415 1 54500 1 73722 1 87107 1
0185T 1 27049 1 36416 1 54505 1 73723 1 87109 1
0186T 2 27050 1 36420 2 54512 1 73725 1 87110 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value0188T 1 27052 1 36425 1 54520 1 74000 3 87116 1
0189T 46 27054 1 36430 1 54522 1 74010 2 87118 1
0190T 2 27057 1 36440 1 54530 1 74020 2 87140 1
0191T 2 27059 1 36450 1 54535 1 74022 2 87143 1
0192T 2 27060 1 36455 1 54550 1 74150 1 87147 1
01953 10 27062 1 36460 75 54560 1 74160 1 87149 1
0195T 1 27065 1 36468 1 54600 1 74170 1 87150 1
0196T 1 27066 1 36469 1 54620 1 74174 1 87152 1
0197T 2 27067 1 36470 1 54640 1 74175 1 87153 1
0198T 2 27070 1 36471 1 54650 1 74176 1 87158 1
01996 1 27071 1 36475 1 54660 1 74177 1 87164 1
0199T 1 27075 1 36476 1 54670 1 74178 1 87166 1
0200T 1 27076 1 36478 1 54680 1 74181 1 87168 1
0201T 1 27077 1 36479 1 54690 1 74182 1 87169 1
0202T 1 27078 1 36481 1 54692 1 74183 1 87172 1
0205T 1 27080 1 36500 12 54699 1 74185 1 87176 1
0206T 1 27086 1 36510 1 54700 1 74190 1 87177 1
0207T 1 27087 1 36511 1 54800 1 74210 1 87181 1
0208T 1 27090 1 36512 1 54830 1 74220 1 87184 1
0209T 1 27091 1 36513 1 54840 1 74230 1 87185 1
0210T 1 27093 1 36514 1 54860 1 74235 1 87186 1
0211T 1 27095 1 36515 1 54861 1 74240 1 87187 1
0212T 1 27096 1 36516 1 54865 1 74241 1 87188 1
0213T 1 27097 1 36522 1 54900 1 74245 1 87190 1
0214T 1 27098 1 36555 2 54901 1 74246 1 87197 1
0215T 1 27100 1 36556 2 55000 1 74247 1 87205 1
0216T 1 27105 1 36557 1 55040 1 74249 1 87206 1
0217T 1 27110 1 36558 1 55041 1 74250 1 87207 1
0218T 1 27111 1 36560 1 55060 1 74251 1 87209 1
0219T 1 27120 1 36561 1 55100 2 74260 1 87210 1
0220T 1 27122 1 36563 1 55110 1 74261 1 87220 1
0221T 1 27125 1 36565 1 55120 1 74262 1 87230 1
0222T 21 27130 1 36566 1 55150 1 74263 1 87250 1
0223T 1 27132 1 36568 1 55175 1 74270 1 87252 1
0224T 1 27134 1 36569 1 55180 1 74280 1 87253 1
0225T 1 27137 1 36570 1 55200 1 74283 1 87254 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value0226T 1 27138 1 36571 1 55250 1 74290 1 87255 1
0227T 1 27140 1 36575 1 55300 1 74291 1 87260 1
0228T 1 27146 1 36576 1 55400 1 74300 1 87265 1
0229T 18 27147 1 36578 1 55450 1 74301 2 87267 1
0230T 1 27151 1 36580 1 55500 1 74305 1 87269 1
0231T 5 27156 1 36581 1 55520 1 74320 1 87270 1
0232T 1 27158 1 36582 1 55530 1 74327 1 87271 1
0233T 1 27161 1 36583 1 55535 1 74328 1 87272 1
0234T 2 27165 1 36584 1 55540 1 74329 1 87273 1
0235T 2 27170 1 36585 1 55550 1 74330 1 87274 1
0236T 1 27175 1 36589 1 55559 1 74340 1 87275 1
0237T 2 27176 1 36590 1 55600 1 74355 1 87276 1
0238T 100 27177 1 36591 2 55605 1 74360 1 87277 1
0239T 1 27178 1 36592 1 55650 1 74363 2 87278 1
0240T 1 27179 1 36593 2 55680 1 74400 1 87279 1
0241T 1 27181 1 36595 1 55700 1 74410 1 87280 1
0243T 1 27185 1 36596 1 55705 1 74415 1 87281 1
0244T 1 27187 1 36597 1 55706 1 74420 2 87283 1
0245T 1 27193 1 36598 1 55720 1 74425 1 87285 1
0246T 1 27194 1 36600 2 55725 1 74430 1 87290 1
0247T 1 27200 1 36620 3 55801 1 74440 1 87299 1
0248T 1 27202 1 36625 2 55810 1 74445 1 87300 1
0249T 1 27215 1 36640 1 55812 1 74450 1 87301 1
0253T 1 27216 1 36660 1 55815 1 74455 1 87305 1
0254T 1 27217 1 36680 1 55821 1 74470 2 87320 1
0255T 1 27218 1 36800 1 55831 1 74475 2 87324 1
0260T 1 27220 1 36810 1 55840 1 74480 2 87327 1
0261T 1 27222 1 36815 1 55842 1 74485 2 87328 1
0262T 1 27226 1 36818 1 55845 1 74710 1 87329 1
0263T 1 27227 1 36819 1 55860 1 74740 1 87332 1
0264T 1 27228 1 36820 1 55862 1 74742 2 87335 1
0265T 1 27230 1 36821 2 55865 1 74775 1 87336 1
0266T 1 27232 1 36822 1 55866 1 75557 1 87337 1
0267T 1 27235 1 36823 1 55870 1 75559 1 87338 1
0268T 1 27236 1 36825 1 55873 1 75561 1 87339 1
0269T 1 27238 1 36830 2 55875 1 75563 1 87340 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value0270T 1 27240 1 36831 1 55876 1 75565 1 87341 1
0271T 1 27244 1 36832 2 55899 999 75571 1 87350 1
0272T 1 27245 1 36833 1 55920 1 75572 1 87380 1
0273T 1 27246 1 36835 1 55970 1 75573 1 87385 1
0274T 1 27248 1 36838 1 55980 1 75574 1 87389 1
0275T 1 27250 1 36860 2 56405 2 75600 1 87390 1
0278T 1 27252 1 36861 2 56420 1 75605 1 87391 1
0281T 1 27253 1 36870 1 56440 1 75625 1 87400 1
0282T 1 27254 1 37140 1 56441 1 75630 1 87420 1
0283T 1 27256 1 37145 1 56442 1 75635 1 87425 1
0284T 1 27257 1 37160 1 56501 1 75658 2 87427 1
0285T 1 27258 1 37180 1 56515 1 75705 30 87430 1
0286T 1 27259 1 37181 1 56605 1 75710 1 87449 1
0287T 2 27265 1 37182 1 56606 6 75716 1 87450 1
0288T 1 27266 1 37183 1 56620 1 75726 3 87451 1
0289T 1 27267 1 37184 1 56625 1 75731 1 87470 1
0290T 1 27268 1 37185 2 56630 1 75733 1 87471 1
0291T 1 27269 1 37186 2 56631 1 75736 2 87472 1
0292T 100 27275 1 37187 1 56632 1 75741 1 87475 1
0293T 1 27280 1 37188 1 56633 1 75743 1 87476 1
0294T 1 27282 1 37191 1 56634 1 75746 1 87477 1
0295T 1 27284 1 37192 1 56637 1 75756 2 87480 1
0296T 1 27286 1 37193 1 56640 1 75774 5 87481 1
0297T 1 27290 1 37195 1 56700 1 75791 1 87482 1
0298T 1 27295 1 37197 2 56740 1 75801 1 87485 1
0299T 1 27299 1 37200 2 56800 1 75803 1 87486 1
0300T 100 27301 1 37202 1 56805 1 75805 1 87487 1
0301T 1 27303 1 37204 2 56810 1 75807 1 87490 1
0302T 1 27305 1 37205 1 56820 1 75809 1 87491 1
0303T 1 27306 1 37206 12 56821 1 75810 1 87492 1
0304T 1 27307 1 37207 1 57000 1 75820 1 87493 1
0305T 1 27310 1 37208 2 57010 1 75822 1 87495 1
0306T 1 27323 1 37210 1 57020 1 75825 1 87496 1
0307T 1 27324 1 37211 1 57022 2 75827 1 87497 1
0308T 1 27325 1 37212 1 57023 2 75831 1 87498 1
0309T 1 27326 1 37213 1 57061 1 75833 1 87500 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value0310T 1 27327 1 37214 1 57065 1 75840 1 87501 1
0311T 1 27328 1 37215 1 57100 3 75842 1 87502 1
0312T 1 27329 1 37216 1 57105 2 75860 2 87503 1
0313T 1 27330 1 37220 1 57106 1 75870 1 87510 1
0314T 1 27331 1 37221 1 57107 1 75872 1 87511 1
0315T 1 27332 1 37222 2 57109 1 75880 2 87512 1
0316T 1 27333 1 37223 2 57110 1 75885 1 87515 1
0317T 1 27334 1 37224 1 57111 1 75887 1 87516 1
0318T 1 27335 1 37225 1 57112 1 75889 1 87517 1
0319T 1 27337 1 37226 1 57120 1 75891 1 87520 1
0320T 1 27339 1 37227 1 57130 1 75893 12 87521 1
0321T 1 27340 1 37228 1 57135 2 75894 2 87522 1
0322T 1 27345 1 37229 1 57150 1 75896 3 87525 1
0323T 1 27347 1 37230 1 57155 1 75898 1 87526 1
0324T 1 27350 1 37231 1 57156 1 75901 1 87527 1
0325T 1 27355 1 37232 2 57160 1 75902 2 87528 1
0326T 1 27356 1 37233 2 57170 1 75945 1 87529 2
0327T 1 27357 1 37234 2 57180 1 75946 12 87530 1
0328T 1 27358 1 37235 2 57200 1 75952 1 87531 1
10021 2 27360 1 37250 1 57210 1 75953 4 87532 1
10022 3 27364 3 37251 12 57220 1 75954 2 87533 1
10040 1 27365 1 37500 1 57230 1 75956 1 87534 1
10060 1 27370 1 37501 1 57240 1 75957 1 87535 1
10061 1 27372 1 37565 1 57250 1 75958 2 87536 1
10080 1 27380 1 37600 1 57260 1 75959 1 87537 1
10081 1 27381 1 37605 2 57265 1 75960 3 87538 1
10120 1 27385 1 37606 2 57267 3 75962 1 87539 1
10121 2 27386 1 37607 1 57268 1 75964 4 87540 1
10140 16 27390 1 37609 1 57270 1 75966 1 87541 1
10160 2 27391 1 37615 2 57280 1 75968 2 87542 1
10180 3 27392 1 37616 1 57282 1 75970 2 87550 1
11000 1 27393 1 37617 3 57283 1 75978 3 87551 1
11001 9 27394 1 37618 2 57284 1 75980 1 87552 1
11004 1 27395 1 37619 1 57285 1 75982 2 87555 1
11005 1 27396 1 37650 1 57287 1 75984 2 87556 1
11006 1 27397 1 37660 1 57288 1 75989 2 87557 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value11008 1 27400 1 37700 1 57289 1 76000 3 87560 1
11010 1 27403 1 37718 1 57291 1 76001 2 87561 1
11011 1 27405 1 37722 1 57292 1 76010 2 87562 1
11012 1 27407 1 37735 1 57295 1 76080 2 87580 1
11042 1 27409 1 37760 1 57296 1 76098 2 87581 1
11043 1 27412 1 37761 1 57300 1 76100 2 87582 1
11044 1 27415 1 37765 1 57305 1 76101 1 87590 1
11045 14 27416 1 37766 1 57307 1 76102 1 87591 1
11046 70 27418 1 37780 1 57308 1 76120 1 87592 1
11047 44 27420 1 37785 1 57310 1 76125 1 87620 1
11055 1 27422 1 37788 1 57311 1 76140 3 87621 1
11056 1 27424 1 37790 1 57320 1 76376 2 87622 1
11057 1 27425 1 37799 999 57330 1 76377 2 87631 1
11100 1 27427 1 38100 1 57335 1 76380 1 87632 1
11101 5 27428 1 38101 1 57400 1 76390 1 87633 1
11200 1 27429 1 38102 1 57410 1 76496 999 87640 1
11201 1 27430 1 38115 1 57415 1 76497 999 87641 1
11300 6 27435 1 38120 1 57420 1 76498 999 87650 1
11301 4 27437 1 38129 999 57421 1 76499 999 87651 1
11302 4 27438 1 38200 1 57423 1 76506 1 87652 1
11303 14 27440 1 38204 1 57425 1 76510 1 87653 1
11305 5 27441 1 38205 1 57426 1 76511 1 87660 1
11306 4 27442 1 38206 1 57452 1 76512 1 87797 1
11307 4 27443 1 38207 1 57454 1 76513 1 87798 1
11308 12 27445 1 38208 2 57455 1 76514 1 87799 1
11310 4 27446 1 38209 100 57456 1 76516 1 87800 1
11311 4 27447 1 38210 1 57460 1 76519 1 87801 1
11312 4 27448 1 38211 1 57461 1 76529 1 87802 1
11313 4 27450 1 38212 1 57500 1 76536 1 87803 1
11400 5 27454 1 38213 1 57505 1 76604 1 87804 1
11401 4 27455 1 38214 1 57510 1 76645 1 87807 1
11402 4 27457 1 38215 1 57511 1 76700 1 87808 1
11403 3 27465 1 38220 1 57513 1 76705 2 87809 1
11404 2 27466 1 38221 1 57520 1 76770 1 87810 1
11406 3 27468 1 38230 1 57522 1 76775 2 87850 1
11420 6 27470 1 38232 1 57530 1 76776 1 87880 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value11421 4 27472 1 38240 1 57531 1 76800 1 87899 1
11422 4 27475 1 38241 1 57540 1 76801 1 87900 1
11423 2 27477 1 38242 1 57545 1 76802 3 87901 1
11424 2 27479 1 38243 1 57550 1 76805 1 87902 1
11426 2 27485 1 38300 2 57555 1 76810 3 87903 1
11440 4 27486 1 38305 2 57556 1 76811 1 87904 20
11441 4 27487 1 38308 1 57558 1 76812 3 87905 1
11442 2 27488 1 38380 1 57700 1 76813 1 87906 1
11443 2 27495 1 38381 1 57720 1 76814 3 87910 1
11444 6 27496 1 38382 1 57800 1 76815 1 87912 1
11446 3 27497 1 38500 1 58100 1 76816 5 87999 999
11450 1 27498 1 38505 1 58110 1 76817 1 88000 1
11451 1 27499 1 38510 1 58120 1 76818 4 88005 1
11462 1 27500 1 38520 1 58140 1 76819 2 88007 1
11463 1 27501 1 38525 1 58145 1 76820 2 88012 1
11470 3 27502 1 38530 1 58146 1 76821 1 88014 1
11471 2 27503 1 38542 1 58150 1 76825 1 88016 1
11600 2 27506 1 38550 1 58152 1 76826 5 88020 1
11601 2 27507 1 38555 1 58180 1 76827 4 88025 1
11602 2 27508 1 38562 1 58200 1 76828 4 88027 1
11603 2 27509 1 38564 1 58210 1 76830 1 88028 1
11604 2 27510 1 38570 1 58240 1 76831 1 88029 1
11606 2 27511 1 38571 1 58260 1 76856 1 88036 100
11620 10 27513 1 38572 1 58262 1 76857 1 88037 100
11621 2 27514 1 38589 1 58263 1 76870 1 88040 1
11622 2 27516 1 38700 1 58267 1 76872 1 88045 1
11623 2 27517 1 38720 1 58270 1 76873 1 88099 999
11624 7 27519 1 38724 1 58275 1 76881 2 88104 4
11626 2 27520 1 38740 1 58280 1 76882 2 88106 3
11640 8 27524 1 38745 1 58285 1 76885 1 88108 3
11641 2 27530 1 38746 1 58290 1 76886 1 88112 2
11642 2 27532 1 38747 1 58291 1 76930 1 88120 2
11643 2 27535 1 38760 1 58292 1 76932 1 88121 2
11644 2 27536 1 38765 1 58293 1 76936 2 88125 1
11646 3 27538 1 38770 1 58294 1 76937 2 88130 1
11719 1 27540 1 38780 1 58300 1 76940 1 88140 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value11720 1 27550 1 38790 1 58301 1 76941 3 88141 1
11721 1 27552 1 38792 1 58321 1 76942 1 88142 1
11730 1 27556 1 38794 1 58322 1 76945 1 88143 1
11732 1 27557 1 38900 1 58323 1 76946 1 88147 1
11740 1 27558 1 38999 999 58340 1 76948 1 88148 1
11750 1 27560 1 39000 1 58345 1 76950 2 88150 1
11752 1 27562 1 39010 1 58346 1 76965 2 88152 1
11755 1 27566 1 39200 1 58350 1 76970 1 88153 1
11760 1 27570 1 39220 1 58353 1 76975 1 88154 1
11762 1 27580 1 39400 1 58356 1 76977 1 88155 1
11765 1 27590 1 39499 999 58400 1 76998 1 88160 4
11770 1 27591 1 39501 1 58410 1 76999 999 88161 4
11771 1 27592 1 39503 1 58520 1 77001 1 88162 3
11772 1 27594 1 39540 1 58540 1 77002 1 88164 1
11900 1 27596 1 39541 1 58541 1 77003 1 88165 1
11901 1 27598 1 39545 1 58542 1 77011 1 88166 1
11920 1 27599 1 39560 1 58543 1 77012 1 88167 1
11921 1 27600 1 39561 1 58544 1 77013 1 88172 3
11922 1 27601 1 39599 999 58545 1 77014 2 88173 3
11950 1 27602 1 40490 2 58546 1 77021 1 88174 1
11951 1 27603 1 40500 2 58548 1 77022 1 88175 1
11952 1 27604 1 40510 2 58550 1 77031 2 88177 2
11954 1 27605 1 40520 2 58552 1 77032 2 88182 2
11960 3 27606 1 40525 2 58553 1 77051 1 88184 1
11970 1 27607 1 40527 2 58554 1 77052 1 88185 72
11971 1 27610 1 40530 2 58555 1 77053 2 88187 1
11976 1 27612 1 40650 2 58558 1 77054 2 88188 1
11980 1 27613 1 40652 2 58559 1 77055 1 88189 1
11981 1 27614 1 40654 2 58560 1 77056 1 88199 999
11982 1 27615 1 40700 1 58561 1 77057 1 88230 2
11983 1 27616 1 40701 1 58562 1 77058 1 88233 3
12001 1 27618 1 40702 1 58563 1 77059 1 88235 10
12002 1 27619 1 40720 1 58565 1 77071 1 88237 2
12004 1 27620 1 40761 1 58570 1 77072 1 88239 3
12005 1 27625 1 40799 999 58571 1 77073 1 88240 3
12006 1 27626 1 40800 1 58572 1 77074 1 88241 3
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value12007 1 27630 1 40801 1 58573 1 77075 1 88245 1
12011 1 27632 1 40804 4 58578 1 77076 1 88248 1
12013 1 27634 1 40805 8 58579 1 77077 1 88249 1
12014 1 27635 1 40806 2 58600 1 77078 1 88261 1
12015 1 27637 1 40808 3 58605 1 77080 1 88262 1
12016 1 27638 1 40810 2 58611 1 77081 1 88263 1
12017 1 27640 1 40812 2 58615 1 77082 1 88264 1
12018 1 27641 1 40814 2 58660 1 77084 1 88267 1
12020 3 27645 1 40816 2 58661 1 77261 1 88269 1
12021 3 27646 1 40818 2 58662 1 77262 1 88271 72
12031 1 27647 1 40819 2 58670 1 77263 1 88272 30
12032 1 27648 1 40820 2 58671 1 77280 1 88273 3
12034 1 27650 1 40830 2 58672 1 77285 1 88274 15
12035 1 27652 1 40831 2 58673 1 77290 1 88275 8
12036 1 27654 1 40840 1 58679 1 77295 1 88280 4
12037 1 27656 1 40842 1 58700 1 77299 999 88283 2
12041 1 27658 2 40843 1 58720 1 77300 18 88285 32
12042 1 27659 2 40844 2 58740 1 77301 1 88289 1
12044 1 27664 2 40845 1 58750 1 77305 2 88291 1
12045 1 27665 2 40899 999 58752 1 77310 2 88299 999
12046 1 27675 1 41000 1 58760 1 77315 2 88300 2
12047 1 27676 1 41005 1 58770 1 77321 1 88302 2
12051 1 27680 3 41006 2 58800 1 77326 1 88304 6
12052 1 27681 1 41007 2 58805 1 77327 1 88305 12
12053 1 27685 1 41008 2 58820 1 77328 1 88307 7
12054 1 27686 1 41009 2 58822 1 77331 18 88309 3
12055 1 27687 1 41010 1 58823 2 77332 4 88311 4
12056 1 27690 1 41015 2 58825 1 77333 4 88312 8
12057 1 27691 1 41016 1 58900 1 77334 18 88313 10
13100 1 27692 9 41017 2 58920 1 77336 1 88314 28
13101 1 27695 1 41018 2 58925 1 77338 1 88319 40
13102 7 27696 1 41019 1 58940 1 77370 1 88321 1
13120 1 27698 1 41100 3 58943 1 77371 1 88323 1
13121 1 27700 1 41105 3 58950 1 77372 1 88325 1
13122 7 27702 1 41108 2 58951 1 77373 1 88329 4
13131 1 27703 1 41110 2 58952 1 77399 999 88331 11
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value13132 1 27704 1 41112 2 58953 1 77401 2 88332 10
13133 20 27705 1 41113 2 58954 1 77402 2 88333 1
13150 1 27707 1 41114 2 58956 1 77403 2 88334 16
13151 1 27709 1 41115 1 58957 1 77404 2 88342 12
13152 1 27712 1 41116 3 58958 1 77406 2 88346 45
13153 8 27715 1 41120 1 58960 1 77407 2 88347 4
13160 3 27720 1 41130 1 58970 1 77408 2 88348 1
14000 2 27722 1 41135 1 58974 1 77409 2 88349 1
14001 2 27724 1 41140 1 58976 2 77411 2 88355 1
14020 2 27725 1 41145 1 58999 999 77412 2 88356 1
14021 2 27726 1 41150 1 59000 6 77413 2 88358 2
14040 2 27727 1 41153 1 59001 2 77414 2 88360 8
14041 2 27730 1 41155 1 59012 4 77416 2 88361 9
14060 2 27732 1 41250 2 59015 8 77417 1 88362 1
14061 2 27734 1 41251 2 59020 1 77418 2 88363 1
14301 2 27740 1 41252 2 59025 1 77421 2 88365 4
14302 58 27742 1 41500 1 59030 5 77422 1 88367 5
14350 1 27745 1 41510 1 59050 1 77423 1 88368 10
15002 1 27750 1 41512 1 59051 1 77424 1 88371 1
15003 73 27752 1 41520 1 59070 1 77425 1 88372 1
15004 1 27756 1 41530 1 59072 1 77427 1 88375 1
15005 42 27758 1 41599 999 59074 1 77431 1 88380 1
15040 1 27759 1 41800 2 59076 1 77432 1 88381 1
15050 1 27760 1 41805 8 59100 1 77435 1 88387 3
15100 1 27762 1 41806 4 59120 1 77469 1 88388 3
15101 74 27766 1 41820 4 59121 1 77470 1 88399 999
15110 1 27767 1 41821 1 59130 1 77499 999 88720 1
15111 100 27768 1 41822 1 59135 1 77520 1 88738 1
15115 1 27769 1 41823 1 59136 1 77522 1 88740 1
15116 2 27780 1 41825 2 59140 1 77523 1 88741 1
15120 1 27781 1 41826 2 59150 1 77525 1 88749 999
15121 14 27784 1 41827 2 59151 1 77600 1 89049 1
15130 1 27786 1 41828 4 59160 1 77605 1 89050 2
15131 100 27788 1 41830 10 59200 1 77610 1 89051 2
15135 1 27792 1 41850 2 59300 1 77615 1 89055 2
15136 100 27808 1 41870 50 59320 1 77620 1 89060 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value15150 1 27810 1 41872 4 59325 1 77750 1 89125 2
15151 1 27814 1 41874 4 59350 1 77761 1 89160 1
15152 2 27816 1 41899 999 59400 1 77762 1 89190 1
15155 1 27818 1 42000 1 59409 1 77763 1 89220 1
15156 1 27822 1 42100 3 59410 1 77776 1 89230 1
15157 100 27823 1 42104 3 59412 2 77777 1 89240 999
15200 1 27824 1 42106 2 59414 1 77778 1 89250 1
15201 10 27825 1 42107 2 59425 1 77785 3 89251 1
15220 1 27826 1 42120 1 59426 1 77786 3 89253 1
15221 13 27827 1 42140 1 59430 1 77787 3 89254 1
15240 1 27828 1 42145 1 59510 1 77789 2 89255 1
15241 9 27829 1 42160 1 59514 1 77790 2 89257 1
15260 1 27830 1 42180 1 59515 1 77799 999 89258 1
15261 9 27831 1 42182 1 59525 1 78012 1 89259 1
15271 1 27832 1 42200 1 59610 1 78013 1 89260 1
15272 3 27840 1 42205 1 59612 1 78014 1 89261 1
15273 1 27842 1 42210 1 59614 1 78015 1 89264 1
15274 100 27846 1 42215 1 59618 1 78016 1 89268 1
15275 1 27848 1 42220 1 59620 1 78018 1 89272 1
15276 3 27860 1 42225 1 59622 1 78020 1 89280 1
15277 1 27870 1 42226 1 59812 1 78070 1 89281 1
15278 100 27871 1 42227 1 59820 1 78071 1 89290 1
15570 3 27880 1 42235 1 59821 1 78072 1 89291 1
15572 2 27881 1 42260 1 59830 1 78075 1 89300 1
15574 2 27882 1 42280 1 59840 1 78099 999 89310 1
15576 2 27884 1 42281 1 59841 1 78102 1 89320 1
15600 2 27886 1 42299 999 59850 1 78103 1 89321 1
15610 2 27888 1 42300 2 59851 1 78104 1 89322 1
15620 2 27889 1 42305 2 59852 1 78110 1 89325 1
15630 2 27892 1 42310 2 59855 1 78111 1 89329 1
15650 1 27893 1 42320 2 59856 1 78120 1 89330 1
15731 1 27894 1 42330 3 59857 1 78121 1 89331 1
15732 7 27899 1 42335 2 59866 1 78122 1 89335 1
15734 9 28001 2 42340 1 59870 1 78130 1 89342 1
15736 4 28002 3 42400 2 59871 1 78135 1 89343 1
15738 3 28003 2 42405 2 59897 999 78140 1 89344 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value15740 3 28005 3 42408 1 59898 1 78185 1 89346 1
15750 2 28008 1 42409 1 59899 999 78190 1 89352 1
15756 2 28010 1 42410 1 60000 1 78191 1 89353 1
15757 3 28011 1 42415 1 60100 2 78195 1 89354 1
15758 3 28020 3 42420 1 60200 2 78199 999 89356 2
15760 2 28022 10 42425 1 60210 1 78201 1 89398 999
15770 2 28024 2 42426 1 60212 1 78202 1 90281 1
15775 1 28035 1 42440 1 60220 1 78205 1 90283 1
15776 1 28039 3 42450 1 60225 1 78206 1 90284 1
15777 1 28041 3 42500 2 60240 1 78215 1 90287 1
15780 1 28043 1 42505 1 60252 1 78216 1 90288 1
15781 2 28045 1 42507 1 60254 1 78226 1 90291 1
15782 2 28046 1 42508 1 60260 1 78227 1 90296 1
15783 2 28047 1 42509 1 60270 1 78230 1 90371 1
15786 1 28050 1 42510 1 60271 1 78231 1 90375 20
15787 3 28052 1 42550 2 60280 1 78232 1 90376 20
15788 1 28054 1 42600 1 60281 1 78258 1 90378 3
15789 1 28055 1 42650 2 60300 10 78261 1 90384 1
15792 1 28060 1 42660 2 60500 1 78262 1 90385 1
15793 1 28062 1 42665 2 60502 1 78264 1 90386 1
15819 1 28070 12 42699 999 60505 1 78267 1 90389 1
15820 1 28072 1 42700 2 60512 1 78268 1 90393 1
15821 1 28080 2 42720 1 60520 1 78270 1 90396 1
15822 1 28086 1 42725 2 60521 1 78271 1 90399 999
15823 1 28088 1 42800 3 60522 1 78272 1 90460 10
15824 1 28090 1 42802 2 60540 1 78278 2 90461 6
15825 1 28092 2 42804 4 60545 1 78282 1 90471 1
15826 1 28100 1 42806 1 60600 1 78290 1 90472 8
15828 1 28102 1 42808 2 60605 1 78291 1 90473 1
15829 1 28103 1 42809 1 60650 1 78299 999 90474 8
15830 1 28104 8 42810 1 60659 1 78300 1 90476 1
15832 1 28106 2 42815 1 60699 999 78305 1 90477 1
15833 1 28107 2 42820 1 61000 1 78306 1 90581 1
15834 1 28108 2 42821 1 61001 1 78315 1 90585 1
15835 1 28110 1 42825 1 61020 2 78320 1 90586 1
15836 1 28111 1 42826 1 61026 2 78350 1 90632 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value15837 1 28112 1 42830 1 61050 1 78351 1 90633 1
15838 1 28113 1 42831 1 61055 1 78399 999 90634 1
15839 2 28114 1 42835 1 61070 2 78414 1 90636 1
15840 1 28116 1 42836 1 61105 2 78428 1 90644 1
15841 2 28118 1 42842 1 61107 2 78445 1 90645 1
15842 2 28119 1 42844 1 61108 2 78451 1 90646 1
15845 2 28120 1 42845 1 61120 1 78452 1 90647 1
15847 1 28122 1 42860 1 61140 2 78453 1 90648 1
15850 1 28124 1 42870 1 61150 2 78454 1 90649 1
15851 1 28126 1 42890 1 61151 2 78456 1 90650 1
15852 2 28130 1 42892 1 61154 1 78457 1 90653 1
15860 1 28140 5 42894 1 61156 2 78458 1 90654 1
15876 1 28150 1 42900 1 61210 1 78459 1 90655 1
15877 1 28153 1 42950 1 61215 1 78466 1 90656 1
15878 1 28160 1 42953 1 61250 1 78468 1 90657 1
15879 1 28171 2 42955 1 61253 1 78469 1 90658 1
15920 1 28173 2 42960 1 61304 1 78472 1 90660 1
15922 1 28175 2 42961 1 61305 1 78473 1 90661 1
15931 1 28190 1 42962 1 61312 2 78481 1 90662 1
15933 1 28192 1 42970 1 61313 2 78483 1 90664 1
15934 1 28193 1 42971 1 61314 2 78491 1 90666 1
15935 1 28200 6 42972 1 61315 1 78492 1 90667 1
15936 1 28202 2 42999 999 61316 1 78494 1 90668 1
15937 1 28208 8 43020 1 61320 2 78496 1 90669 1
15940 2 28210 2 43030 1 61321 2 78499 999 90670 1
15941 2 28220 1 43045 1 61322 1 78579 1 90672 1
15944 2 28222 1 43100 1 61323 1 78580 1 90675 1
15945 2 28225 1 43101 1 61330 1 78582 1 90676 1
15946 2 28226 1 43107 1 61332 1 78597 1 90680 1
15950 2 28230 1 43108 1 61333 1 78598 1 90681 1
15951 2 28232 1 43112 1 61334 1 78599 999 90685 1
15952 2 28234 2 43113 1 61340 1 78600 1 90686 1
15953 2 28238 1 43116 1 61343 1 78601 1 90687 1
15956 2 28240 1 43117 1 61345 1 78605 1 90688 1
15958 2 28250 1 43118 1 61440 1 78606 2 90690 1
15999 999 28260 1 43121 1 61450 1 78607 1 90691 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value16000 1 28261 1 43122 1 61458 1 78608 1 90692 1
16020 1 28262 1 43123 1 61460 1 78609 1 90693 1
16025 1 28264 1 43124 1 61470 1 78610 1 90696 1
16030 1 28270 1 43130 1 61480 1 78630 2 90698 1
16035 1 28272 2 43135 1 61490 1 78635 1 90700 1
16036 17 28280 1 43200 1 61500 3 78645 1 90702 1
17000 1 28285 1 43201 1 61501 1 78647 1 90703 1
17003 13 28286 1 43202 1 61510 1 78650 1 90704 1
17004 1 28288 10 43204 1 61512 3 78660 1 90705 1
17106 1 28289 1 43205 1 61514 2 78699 999 90706 1
17107 1 28290 1 43206 1 61516 2 78700 1 90707 1
17108 1 28292 1 43215 1 61517 1 78701 2 90708 1
17110 1 28293 1 43216 1 61518 2 78707 1 90710 1
17111 1 28294 1 43217 1 61519 2 78708 1 90712 1
17250 2 28296 1 43219 1 61520 1 78709 1 90713 1
17260 4 28297 1 43220 1 61521 1 78710 1 90714 1
17261 4 28298 1 43226 1 61522 2 78725 1 90715 1
17262 3 28299 1 43227 2 61524 2 78730 1 90716 1
17263 3 28300 1 43228 1 61526 1 78740 1 90717 1
17264 3 28302 1 43231 1 61530 1 78761 1 90719 1
17266 2 28304 1 43232 1 61531 2 78799 999 90720 1
17270 10 28305 1 43235 1 61533 2 78800 1 90721 1
17271 2 28306 1 43236 1 61534 1 78801 1 90723 1
17272 2 28307 1 43237 1 61535 2 78802 1 90725 1
17273 7 28308 4 43238 1 61536 1 78803 1 90727 1
17274 3 28309 1 43239 1 61537 1 78804 1 90732 1
17276 3 28310 1 43240 1 61538 1 78805 1 90733 1
17280 2 28312 1 43241 1 61539 1 78806 1 90734 1
17281 2 28313 1 43242 1 61540 1 78807 1 90735 1
17282 2 28315 1 43243 1 61541 1 78808 1 90736 1
17283 7 28320 1 43244 1 61542 1 78811 1 90738 1
17284 6 28322 2 43245 1 61543 1 78812 1 90739 1
17286 3 28340 1 43246 1 61544 2 78813 1 90740 2
17311 2 28341 1 43247 1 61545 1 78814 1 90743 1
17312 4 28344 1 43248 1 61546 1 78815 1 90744 1
17313 2 28345 8 43249 1 61548 1 78816 1 90746 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value17314 4 28360 1 43250 1 61550 1 78999 999 90747 2
17315 58 28400 1 43251 1 61552 1 79005 1 90748 1
17340 1 28405 1 43252 1 61556 1 79101 1 90749 999
17360 1 28406 1 43255 2 61557 1 79200 1 90785 100
17380 48 28415 1 43256 1 61558 1 79300 1 90791 1
17999 999 28420 1 43257 1 61559 1 79403 1 90792 1
19000 1 28430 1 43258 1 61563 2 79440 1 90832 1
19001 5 28435 1 43259 1 61564 1 79445 1 90833 1
19020 1 28436 1 43260 1 61566 1 79999 999 90834 1
19030 1 28445 1 43261 1 61567 1 80047 2 90836 1
19100 12 28446 1 43262 2 61570 2 80048 2 90837 1
19101 3 28450 5 43263 2 61571 2 80050 3 90838 1
19102 2 28455 5 43264 1 61575 1 80051 2 90839 1
19103 2 28456 5 43265 1 61576 1 80053 1 90840 45
19105 1 28465 5 43267 1 61580 1 80055 1 90845 1
19110 1 28470 5 43268 2 61581 1 80061 1 90846 1
19112 1 28475 5 43269 2 61582 1 80069 1 90847 1
19120 1 28476 5 43271 1 61583 1 80074 1 90849 1
19125 1 28485 5 43272 1 61584 1 80076 1 90853 1
19126 3 28490 1 43273 1 61585 1 80100 10 90863 1
19260 2 28495 1 43279 1 61586 1 80101 14 90865 1
19271 2 28496 1 43280 1 61590 1 80102 6 90867 1
19272 2 28505 1 43281 1 61591 1 80103 2 90868 1
19290 1 28510 1 43282 1 61592 1 80104 1 90869 1
19291 6 28515 1 43283 1 61595 1 80150 2 90870 1
19295 2 28525 1 43289 1 61596 1 80152 2 90875 1
19296 1 28530 1 43300 1 61597 1 80154 2 90876 1
19297 1 28531 1 43305 1 61598 1 80156 2 90880 1
19298 1 28540 1 43310 1 61600 1 80157 2 90882 1
19300 1 28545 1 43312 1 61601 1 80158 2 90885 1
19301 1 28546 1 43313 1 61605 1 80160 2 90887 7
19302 1 28555 1 43314 1 61606 1 80162 2 90889 1
19303 1 28570 1 43320 1 61607 1 80164 2 90899 999
19304 1 28575 1 43325 1 61608 1 80166 2 90901 1
19305 1 28576 1 43327 1 61609 1 80168 2 90911 1
19306 1 28585 1 43328 1 61610 1 80170 2 90935 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value19307 1 28600 3 43330 1 61611 1 80172 2 90937 1
19316 1 28605 3 43331 1 61612 1 80173 2 90940 2
19318 1 28606 5 43332 1 61613 1 80174 2 90945 1
19324 1 28615 5 43333 1 61615 1 80176 1 90947 1
19325 1 28630 1 43334 1 61616 1 80178 2 90951 1
19328 1 28635 1 43335 1 61618 2 80182 2 90952 1
19330 1 28636 1 43336 1 61619 2 80184 2 90953 1
19340 1 28645 1 43337 1 61623 2 80185 2 90954 1
19342 1 28660 2 43338 1 61624 2 80186 2 90955 1
19350 1 28665 2 43340 1 61626 2 80188 2 90956 1
19355 1 28666 2 43341 1 61630 2 80190 2 90957 1
19357 1 28675 2 43350 1 61635 2 80192 2 90958 1
19361 1 28705 1 43351 1 61640 1 80194 2 90959 1
19364 1 28715 1 43352 1 61641 2 80195 2 90960 1
19366 1 28725 1 43360 1 61642 50 80196 2 90961 1
19367 1 28730 1 43361 1 61680 1 80197 2 90962 1
19368 1 28735 1 43400 1 61682 1 80198 2 90963 1
19369 1 28737 1 43401 1 61684 1 80200 2 90964 1
19370 1 28740 12 43405 1 61686 1 80201 2 90965 1
19371 1 28750 1 43410 1 61690 1 80202 2 90966 1
19380 1 28755 1 43415 1 61692 1 80299 3 90967 1
19396 1 28760 1 43420 1 61697 3 80400 1 90968 1
19499 1 28800 1 43425 1 61698 2 80402 1 90969 1
20005 2 28805 1 43450 1 61700 3 80406 1 90970 1
20100 1 28810 1 43453 1 61702 2 80408 1 90989 1
20101 2 28820 1 43456 1 61703 1 80410 1 90993 1
20102 4 28825 1 43458 1 61705 1 80412 1 90997 1
20103 4 28890 1 43460 1 61708 2 80414 1 90999 999
20150 1 28899 999 43496 1 61710 2 80415 1 91010 1
20200 3 29000 1 43499 999 61711 1 80416 1 91013 1
20205 4 29010 1 43500 1 61720 2 80417 1 91020 1
20206 3 29015 1 43501 1 61735 2 80418 1 91022 1
20220 2 29020 1 43502 1 61750 2 80420 1 91030 1
20225 4 29025 1 43510 1 61751 3 80422 1 91034 1
20240 2 29035 1 43520 1 61760 1 80424 1 91035 1
20245 2 29040 1 43605 1 61770 1 80426 1 91037 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value20250 3 29044 1 43610 1 61781 1 80428 1 91038 1
20251 3 29046 1 43611 1 61782 1 80430 1 91040 1
20500 3 29049 1 43620 1 61783 1 80432 1 91065 1
20501 5 29055 1 43621 1 61790 1 80434 1 91110 1
20520 2 29058 1 43622 1 61791 1 80435 1 91111 1
20525 6 29065 1 43631 1 61796 1 80436 1 91112 1
20526 1 29075 1 43632 1 61797 4 80438 1 91117 1
20527 1 29085 1 43633 1 61798 1 80439 1 91120 1
20550 1 29086 1 43634 1 61799 4 80440 1 91122 1
20551 1 29105 1 43635 1 61800 1 80500 1 91132 1
20552 1 29125 1 43640 1 61850 1 80502 1 91133 1
20553 1 29126 1 43641 1 61860 1 81000 2 91299 999
20555 1 29130 1 43644 1 61863 1 81001 2 92002 1
20600 1 29131 1 43645 1 61864 1 81002 2 92004 1
20605 1 29200 1 43647 1 61867 1 81003 2 92012 1
20610 1 29240 1 43648 1 61868 2 81005 2 92014 1
20612 2 29260 1 43651 1 61870 1 81007 1 92015 1
20615 4 29280 1 43652 1 61875 1 81015 1 92018 1
20650 6 29305 1 43653 1 61880 1 81020 1 92019 1
20660 1 29325 1 43659 1 61885 1 81025 1 92020 1
20661 1 29345 1 43752 2 61886 1 81050 2 92025 1
20662 1 29355 1 43753 1 61888 1 81099 999 92060 1
20663 1 29358 1 43754 1 62000 1 81161 1 92065 1
20664 1 29365 1 43755 1 62005 1 81200 1 92071 1
20665 1 29405 1 43756 1 62010 1 81201 1 92072 1
20670 2 29425 1 43757 1 62100 1 81202 1 92081 1
20680 1 29435 1 43760 2 62115 1 81203 1 92082 1
20690 6 29440 1 43761 2 62116 1 81205 1 92083 1
20692 3 29445 1 43770 1 62117 1 81206 1 92100 1
20693 2 29450 1 43771 1 62120 1 81207 1 92132 1
20694 2 29505 1 43772 1 62121 1 81208 1 92133 1
20696 2 29515 1 43773 1 62140 1 81209 1 92134 1
20697 4 29520 1 43774 1 62141 1 81210 1 92136 1
20802 1 29530 1 43775 1 62142 2 81211 1 92140 1
20805 1 29540 1 43800 1 62143 2 81212 1 92225 1
20808 1 29550 1 43810 1 62145 2 81213 1 92226 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value20816 1 29580 1 43820 1 62146 2 81214 1 92227 1
20822 1 29581 1 43825 1 62147 2 81215 1 92228 1
20824 1 29582 1 43830 1 62148 2 81216 1 92230 1
20827 1 29583 1 43831 1 62160 1 81217 1 92235 1
20838 1 29584 1 43832 1 62161 1 81220 1 92240 1
20900 2 29700 2 43840 2 62162 1 81221 1 92250 1
20902 2 29705 1 43842 1 62163 1 81222 1 92260 1
20910 2 29710 1 43843 1 62164 1 81223 1 92265 1
20912 1 29715 1 43845 1 62165 1 81224 1 92270 1
20920 2 29720 1 43846 1 62180 1 81225 1 92275 1
20922 2 29730 2 43847 1 62190 1 81226 1 92283 1
20924 4 29740 1 43848 1 62192 1 81227 1 92284 1
20926 2 29750 1 43850 1 62194 2 81228 1 92285 1
20930 1 29799 999 43855 1 62200 1 81229 1 92286 1
20931 1 29800 1 43860 1 62201 1 81235 1 92287 1
20936 1 29804 1 43865 1 62220 1 81240 1 92310 1
20937 1 29805 1 43870 1 62223 1 81241 1 92311 1
20938 1 29806 1 43880 1 62225 2 81242 1 92312 1
20950 16 29807 1 43881 1 62230 2 81243 1 92313 1
20955 1 29819 1 43882 1 62252 2 81244 1 92314 1
20956 1 29820 1 43886 1 62256 1 81245 1 92315 1
20957 1 29821 1 43887 1 62258 1 81250 1 92316 1
20962 1 29822 1 43888 1 62263 1 81251 1 92317 1
20969 2 29823 1 43999 999 62264 1 81252 1 92325 1
20970 2 29824 1 44005 1 62267 2 81253 1 92326 2
20972 2 29825 1 44010 1 62268 1 81254 1 92340 1
20973 1 29826 1 44015 1 62269 2 81255 1 92341 1
20974 1 29827 1 44020 2 62270 2 81256 1 92342 1
20975 1 29828 1 44021 1 62272 1 81257 1 92352 1
20979 1 29830 1 44025 1 62273 2 81260 1 92353 1
20982 1 29834 1 44050 1 62280 1 81261 1 92354 1
20985 2 29835 1 44055 1 62281 1 81262 1 92355 1
20999 999 29836 1 44100 1 62282 1 81263 1 92358 1
21010 1 29837 1 44110 1 62284 1 81264 1 92370 1
21011 16 29838 1 44111 1 62287 1 81265 1 92371 1
21012 3 29840 1 44120 1 62290 5 81266 1 92499 999
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value21013 6 29843 1 44121 6 62291 19 81267 1 92502 1
21014 3 29844 1 44125 1 62292 1 81268 1 92504 1
21015 1 29845 1 44126 1 62294 2 81270 1 92506 1
21016 2 29846 1 44127 1 62310 1 81275 1 92507 1
21025 2 29847 1 44128 2 62311 1 81280 1 92508 1
21026 1 29848 1 44130 1 62318 1 81281 1 92511 1
21029 1 29850 1 44132 1 62319 1 81282 1 92512 1
21030 1 29851 1 44133 1 62350 1 81290 1 92516 1
21031 1 29855 1 44135 1 62351 1 81291 1 92520 1
21032 1 29856 1 44136 1 62355 1 81292 1 92526 1
21034 1 29860 1 44137 1 62360 1 81293 1 92531 3
21040 2 29861 1 44139 1 62361 1 81294 1 92532 2
21044 1 29862 1 44140 1 62362 1 81295 1 92533 4
21045 1 29863 1 44141 1 62365 1 81296 1 92534 4
21046 2 29866 1 44143 1 62367 1 81297 1 92540 1
21047 2 29867 1 44144 1 62368 1 81298 1 92541 1
21048 2 29868 1 44145 1 62369 1 81299 1 92542 1
21049 2 29870 1 44146 1 62370 1 81300 1 92543 4
21050 1 29871 1 44147 1 63001 1 81301 1 92544 1
21060 1 29873 1 44150 1 63003 1 81302 1 92545 1
21070 1 29874 1 44151 1 63005 1 81303 1 92546 1
21073 1 29875 1 44155 1 63011 1 81304 1 92547 10
21076 1 29876 1 44156 1 63012 1 81310 1 92548 1
21077 1 29877 1 44157 1 63015 1 81315 1 92550 1
21079 1 29879 1 44158 1 63016 1 81316 1 92551 2
21080 1 29880 1 44160 1 63017 1 81317 1 92552 1
21081 1 29881 1 44180 1 63020 1 81318 1 92553 1
21082 1 29882 1 44186 1 63030 1 81319 1 92555 1
21083 1 29883 1 44187 1 63035 10 81321 1 92556 1
21084 1 29884 1 44188 1 63040 1 81322 1 92557 1
21085 1 29885 1 44202 1 63042 1 81323 1 92558 1
21086 1 29886 1 44203 2 63043 6 81324 1 92559 3
21087 1 29887 1 44204 1 63044 4 81325 1 92560 6
21088 1 29888 1 44205 1 63045 1 81326 1 92561 1
21089 999 29889 1 44206 1 63046 1 81330 1 92562 1
21100 1 29891 1 44207 1 63047 1 81331 1 92563 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value21110 2 29892 1 44208 1 63048 21 81332 1 92564 1
21116 1 29893 1 44210 1 63050 1 81340 1 92565 1
21120 1 29894 1 44211 1 63051 1 81341 1 92567 1
21121 1 29895 1 44212 1 63055 1 81342 1 92568 1
21122 1 29897 1 44213 1 63056 1 81350 1 92570 1
21123 1 29898 1 44227 1 63057 15 81355 1 92571 1
21125 2 29899 1 44238 1 63064 1 81370 100 92572 1
21127 2 29900 1 44300 1 63066 3 81371 100 92575 1
21137 1 29901 1 44310 1 63075 1 81372 100 92576 1
21138 1 29902 1 44312 1 63076 6 81373 100 92577 1
21139 1 29904 1 44314 1 63077 1 81374 100 92579 1
21141 1 29905 1 44316 1 63078 11 81375 100 92582 1
21142 1 29906 1 44320 1 63081 1 81376 100 92583 1
21143 1 29907 1 44322 1 63082 6 81377 100 92584 1
21145 1 29914 1 44340 1 63085 1 81378 100 92585 1
21146 1 29915 1 44345 1 63086 11 81379 100 92586 1
21147 1 29916 1 44346 1 63087 1 81380 100 92587 1
21150 1 29999 1 44360 1 63088 10 81381 100 92588 1
21151 1 30000 1 44361 1 63090 1 81382 100 92590 1
21154 1 30020 1 44363 1 63091 11 81383 100 92591 1
21155 1 30100 3 44364 1 63101 1 81400 19 92592 1
21159 1 30110 1 44365 1 63102 1 81401 20 92593 1
21160 1 30115 1 44366 1 63103 15 81402 6 92594 1
21172 1 30117 2 44369 1 63170 1 81403 8 92595 1
21175 1 30118 2 44370 1 63172 1 81404 18 92596 1
21179 1 30120 1 44372 1 63173 1 81405 11 92597 1
21180 1 30124 2 44373 1 63180 1 81406 12 92601 1
21181 1 30125 1 44376 1 63182 1 81407 1 92602 1
21182 1 30130 1 44377 1 63185 1 81408 4 92603 1
21183 1 30140 1 44378 1 63190 1 81479 999 92604 1
21184 1 30150 1 44379 1 63191 1 81500 100 92605 1
21188 1 30160 1 44380 1 63194 1 81503 100 92606 2
21193 1 30200 1 44382 1 63195 1 81506 100 92607 1
21194 1 30210 1 44383 1 63196 1 81508 100 92608 46
21195 1 30220 1 44385 1 63197 1 81509 100 92609 1
21196 1 30300 1 44386 1 63198 1 81510 100 92610 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value21198 1 30310 1 44388 1 63199 1 81511 100 92611 1
21199 1 30320 1 44389 1 63200 1 81512 100 92612 1
21206 1 30400 1 44390 1 63250 1 81599 999 92613 1
21208 2 30410 1 44391 1 63251 1 82000 1 92614 1
21209 2 30420 1 44392 1 63252 1 82003 2 92615 1
21210 2 30430 1 44393 1 63265 1 82009 1 92616 1
21215 2 30435 1 44394 1 63266 1 82010 4 92617 1
21230 2 30450 1 44397 1 63267 1 82013 1 92618 46
21235 2 30460 1 44500 1 63268 1 82016 1 92620 1
21240 1 30462 1 44602 1 63270 1 82017 1 92621 92
21242 1 30465 1 44603 1 63271 1 82024 1 92625 1
21243 1 30520 1 44604 1 63272 1 82030 1 92626 1
21244 1 30540 1 44605 1 63273 1 82040 1 92627 92
21245 2 30545 1 44615 1 63275 1 82042 2 92630 1
21246 2 30560 1 44620 2 63276 1 82043 1 92633 1
21247 1 30580 2 44625 1 63277 1 82044 1 92640 24
21248 8 30600 1 44626 1 63278 1 82045 1 92700 999
21249 70 30620 1 44640 2 63280 1 82055 2 92920 1
21255 1 30630 1 44650 2 63281 1 82075 2 92921 2
21256 1 30801 1 44660 1 63282 1 82085 1 92924 1
21260 1 30802 1 44661 1 63283 1 82088 2 92925 2
21261 1 30901 1 44680 1 63285 1 82101 1 92928 1
21263 1 30903 1 44700 1 63286 1 82103 1 92929 2
21267 1 30905 1 44701 1 63287 1 82104 1 92933 1
21268 1 30906 1 44705 1 63290 1 82105 1 92934 2
21270 1 30915 1 44715 1 63295 1 82106 4 92937 1
21275 1 30920 1 44720 2 63300 1 82107 1 92938 2
21280 1 30930 1 44721 2 63301 1 82108 1 92941 1
21282 1 30999 999 44799 999 63302 1 82120 1 92943 1
21295 1 31000 1 44800 1 63303 1 82127 2 92944 2
21296 1 31002 1 44820 2 63304 1 82128 2 92950 3
21299 999 31020 1 44850 1 63305 1 82131 3 92953 2
21310 1 31030 1 44899 999 63306 1 82135 1 92960 2
21315 1 31032 1 44900 1 63307 1 82136 3 92961 1
21320 1 31040 1 44901 1 63308 24 82139 3 92970 1
21325 1 31050 1 44950 1 63600 2 82140 2 92971 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value21330 1 31051 1 44955 1 63610 1 82143 2 92973 2
21335 1 31070 1 44960 1 63615 1 82145 1 92974 1
21336 1 31075 1 44970 1 63620 1 82150 4 92975 1
21337 1 31080 1 44979 1 63621 2 82154 1 92977 1
21338 1 31081 1 45000 1 63650 2 82157 1 92978 1
21339 1 31084 1 45005 1 63655 1 82160 1 92979 2
21340 1 31085 1 45020 1 63661 1 82163 1 92986 1
21343 1 31086 1 45100 1 63662 1 82164 1 92987 1
21344 1 31087 1 45108 1 63663 1 82172 3 92990 1
21345 1 31090 1 45110 1 63664 1 82175 2 92992 1
21346 1 31200 1 45111 1 63685 2 82180 1 92993 1
21347 1 31201 1 45112 1 63688 2 82190 4 92997 1
21348 1 31205 1 45113 1 63700 1 82205 1 92998 2
21355 1 31225 1 45114 1 63702 1 82232 2 93000 3
21356 1 31230 1 45116 1 63704 1 82239 1 93005 3
21360 1 31231 1 45119 1 63706 1 82240 1 93010 4
21365 1 31233 1 45120 1 63707 1 82247 2 93015 2
21366 1 31235 1 45121 1 63709 1 82248 2 93016 2
21385 1 31237 1 45123 1 63710 1 82252 1 93017 2
21386 1 31238 1 45126 1 63740 1 82261 1 93018 2
21387 1 31239 1 45130 1 63741 1 82270 1 93024 1
21390 1 31240 1 45135 1 63744 1 82271 1 93025 1
21395 1 31254 1 45136 1 63746 1 82272 1 93040 3
21400 1 31255 1 45150 1 64400 1 82274 1 93041 2
21401 1 31256 1 45160 1 64402 1 82286 1 93042 3
21406 1 31267 1 45171 1 64405 1 82300 1 93224 1
21407 1 31276 1 45172 1 64408 1 82306 1 93225 1
21408 1 31287 1 45190 1 64410 1 82308 3 93226 1
21421 1 31288 1 45300 1 64412 1 82310 2 93227 1
21422 1 31290 1 45303 1 64413 1 82330 2 93228 1
21423 1 31291 1 45305 1 64415 1 82331 1 93229 1
21431 1 31292 1 45307 1 64416 1 82340 1 93268 1
21432 1 31293 1 45308 1 64417 1 82355 3 93270 1
21433 1 31294 1 45309 1 64418 1 82360 3 93271 1
21435 1 31295 1 45315 1 64420 3 82365 3 93272 1
21436 1 31296 1 45317 1 64421 1 82370 3 93278 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value21440 2 31297 1 45320 1 64425 1 82373 1 93279 1
21445 2 31299 999 45321 1 64430 1 82374 2 93280 1
21450 1 31300 1 45327 1 64435 1 82375 1 93281 1
21451 1 31320 1 45330 1 64445 1 82376 1 93282 1
21452 1 31360 1 45331 1 64446 1 82378 2 93283 1
21453 1 31365 1 45332 1 64447 1 82379 1 93284 1
21454 1 31367 1 45333 1 64448 1 82380 1 93285 1
21461 1 31368 1 45334 1 64449 1 82382 1 93286 2
21462 1 31370 1 45335 1 64450 1 82383 1 93287 2
21465 1 31375 1 45337 1 64455 1 82384 2 93288 1
21470 1 31380 1 45338 1 64479 1 82387 1 93289 1
21480 1 31382 1 45339 1 64480 18 82390 1 93290 1
21485 1 31390 1 45340 1 64483 1 82397 72 93291 1
21490 1 31395 1 45341 1 64484 9 82415 1 93292 1
21495 1 31400 1 45342 1 64490 1 82435 2 93293 1
21497 1 31420 1 45345 1 64491 1 82436 1 93294 1
21499 999 31500 2 45355 1 64492 1 82438 1 93295 1
21501 3 31502 1 45378 1 64493 1 82441 1 93296 1
21502 1 31505 1 45379 1 64494 1 82465 1 93297 1
21510 1 31510 1 45380 1 64495 1 82480 2 93298 1
21550 3 31511 1 45381 1 64505 1 82482 1 93299 1
21552 6 31512 1 45382 2 64508 1 82485 1 93303 1
21554 3 31513 1 45383 1 64510 1 82486 2 93304 1
21555 3 31515 1 45384 1 64517 1 82487 2 93306 1
21556 3 31520 1 45385 1 64520 1 82488 1 93307 1
21557 1 31525 1 45386 1 64530 1 82489 2 93308 1
21558 1 31526 1 45387 1 64550 1 82491 1 93312 1
21600 24 31527 1 45391 1 64553 1 82492 2 93313 1
21610 2 31528 1 45392 1 64555 2 82495 1 93314 1
21615 1 31529 1 45395 1 64561 1 82507 1 93315 1
21616 1 31530 1 45397 1 64565 2 82520 2 93316 1
21620 1 31531 1 45400 1 64566 1 82523 1 93317 1
21627 1 31535 1 45402 1 64568 1 82525 2 93318 1
21630 1 31536 1 45499 999 64569 1 82528 1 93320 1
21632 1 31540 1 45500 1 64570 1 82530 2 93321 1
21685 1 31541 1 45505 1 64575 2 82533 2 93325 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value21700 1 31545 1 45520 1 64580 2 82540 1 93350 1
21705 1 31546 1 45540 1 64581 2 82541 2 93351 1
21720 1 31560 1 45541 1 64585 2 82542 24 93352 1
21725 1 31561 1 45550 1 64590 1 82543 2 93451 1
21740 1 31570 1 45560 1 64595 1 82544 2 93452 1
21742 1 31571 1 45562 1 64600 2 82550 3 93453 1
21743 1 31575 1 45563 1 64605 1 82552 3 93454 1
21750 1 31576 1 45800 1 64610 1 82553 3 93455 1
21800 6 31577 1 45805 1 64611 1 82554 1 93456 1
21805 3 31578 1 45820 1 64612 1 82565 2 93457 1
21810 1 31579 1 45825 1 64613 1 82570 3 93458 1
21820 1 31580 1 45900 1 64614 1 82575 1 93459 1
21825 1 31582 1 45905 1 64615 1 82585 1 93460 1
21899 999 31584 1 45910 1 64620 11 82595 1 93461 1
21920 3 31587 1 45915 1 64630 1 82600 1 93462 1
21925 3 31588 1 45990 1 64632 1 82607 1 93463 1
21930 4 31590 1 45999 999 64633 1 82608 1 93464 1
21931 3 31595 1 46020 1 64634 17 82610 1 93503 2
21932 2 31599 999 46030 1 64635 1 82615 1 93505 1
21933 3 31600 1 46040 2 64636 5 82626 1 93530 1
21935 1 31601 1 46045 2 64640 1 82627 1 93531 1
21936 3 31603 1 46050 2 64650 1 82633 1 93532 1
22010 2 31605 1 46060 2 64653 1 82634 2 93533 1
22015 2 31610 1 46070 1 64680 1 82638 1 93561 1
22100 1 31611 1 46080 1 64681 1 82646 1 93562 3
22101 1 31612 1 46083 2 64702 2 82649 1 93563 1
22102 1 31613 1 46200 1 64704 4 82651 1 93564 1
22103 3 31614 1 46220 2 64708 3 82652 1 93565 1
22110 1 31615 1 46221 1 64712 1 82654 1 93566 1
22112 1 31620 1 46230 1 64713 1 82656 1 93567 1
22114 1 31622 1 46250 1 64714 1 82657 3 93568 1
22116 21 31623 1 46255 1 64716 12 82658 2 93571 1
22206 1 31624 1 46257 1 64718 1 82664 2 93572 2
22207 1 31625 1 46258 1 64719 1 82666 1 93580 1
22208 15 31626 1 46260 1 64721 1 82668 1 93581 1
22210 1 31627 1 46261 1 64722 2 82670 2 93600 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value22212 1 31628 1 46262 1 64726 2 82671 1 93602 1
22214 1 31629 1 46270 1 64727 3 82672 1 93603 1
22216 21 31630 2 46275 1 64732 1 82677 1 93609 1
22220 1 31631 1 46280 1 64734 1 82679 1 93610 1
22222 1 31632 4 46285 1 64736 1 82690 1 93612 1
22224 1 31633 4 46288 1 64738 1 82693 2 93613 1
22226 21 31634 1 46320 2 64740 1 82696 1 93615 1
22305 1 31635 1 46500 1 64742 1 82705 1 93616 1
22310 1 31636 1 46505 1 64744 1 82710 1 93618 1
22315 1 31637 2 46600 1 64746 1 82715 1 93619 1
22318 1 31638 2 46604 1 64752 1 82725 1 93620 1
22319 1 31640 1 46606 1 64755 1 82726 1 93621 1
22325 1 31641 1 46608 1 64760 1 82728 1 93622 1
22326 1 31643 1 46610 1 64761 1 82731 1 93623 1
22327 1 31645 1 46611 1 64763 1 82735 1 93624 1
22328 21 31646 2 46612 1 64766 1 82742 1 93631 1
22505 1 31647 1 46614 1 64771 2 82746 1 93640 1
22520 1 31648 1 46615 1 64772 2 82747 1 93641 1
22521 1 31649 4 46700 1 64774 3 82757 1 93642 1
22522 15 31651 4 46705 1 64776 1 82759 1 93650 1
22523 1 31660 1 46706 2 64778 3 82760 1 93653 1
22524 1 31661 1 46707 1 64782 2 82775 1 93654 1
22525 15 31717 1 46710 1 64783 2 82776 1 93655 1
22526 1 31720 1 46712 1 64784 7 82777 100 93656 1
22527 1 31725 1 46715 1 64786 1 82784 6 93657 1
22532 1 31730 1 46716 1 64787 10 82785 1 93660 1
22533 1 31750 1 46730 1 64788 17 82787 4 93662 1
22534 15 31755 1 46735 1 64790 1 82800 1 93668 32
22548 1 31760 1 46740 1 64792 2 82803 7 93701 1
22551 1 31766 1 46742 1 64795 2 82805 2 93724 2
22552 4 31770 2 46744 1 64802 1 82810 11 93740 2
22554 1 31775 1 46746 1 64804 1 82820 1 93745 1
22556 1 31780 1 46748 1 64809 1 82930 1 93750 1
22558 1 31781 1 46750 1 64818 1 82938 100 93770 2
22585 20 31785 1 46751 1 64820 1 82941 1 93784 1
22586 1 31786 1 46753 1 64821 1 82943 1 93786 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value22590 1 31800 1 46754 1 64822 1 82945 2 93788 1
22595 1 31805 1 46760 1 64823 1 82946 1 93790 1
22600 1 31820 1 46761 1 64831 1 82947 2 93797 2
22610 1 31825 1 46762 1 64832 7 82948 5 93798 2
22612 1 31830 1 46900 1 64834 1 82950 3 93799 999
22614 21 31899 999 46910 1 64835 1 82951 1 93880 1
22630 1 32035 1 46916 1 64836 1 82952 3 93882 1
22632 4 32036 1 46917 1 64837 3 82953 1 93886 1
22633 1 32096 1 46922 1 64840 1 82955 1 93888 1
22634 4 32097 1 46924 1 64856 1 82960 1 93890 1
22800 1 32098 1 46930 1 64857 1 82962 6 93892 1
22802 1 32100 1 46940 1 64858 1 82963 1 93893 1
22804 1 32110 2 46942 1 64859 2 82965 1 93922 1
22808 1 32120 1 46945 1 64861 1 82975 1 93923 1
22810 1 32124 2 46946 1 64862 1 82977 1 93924 1
22812 1 32140 1 46947 1 64864 2 82978 1 93925 1
22818 1 32141 1 46999 999 64865 1 82979 1 93926 1
22819 1 32150 1 47000 3 64866 1 82980 1 93930 1
22830 1 32151 1 47001 3 64868 1 82985 1 93931 1
22840 1 32160 1 47010 3 64870 1 83001 1 93965 1
22841 1 32200 2 47011 3 64872 3 83002 1 93970 1
22842 1 32201 2 47015 1 64874 1 83003 18 93971 1
22843 1 32215 1 47100 3 64876 1 83008 1 93975 1
22844 1 32220 1 47120 1 64885 1 83009 1 93976 1
22845 1 32225 1 47122 1 64886 1 83010 1 93978 1
22846 1 32310 1 47125 1 64890 1 83012 1 93979 1
22847 1 32320 1 47130 1 64891 1 83013 1 93980 1
22848 1 32400 2 47133 1 64892 1 83014 1 93981 1
22849 1 32405 2 47135 1 64893 1 83015 1 93982 1
22850 1 32440 1 47136 1 64895 1 83018 7 93990 2
22851 24 32442 1 47140 1 64896 1 83020 2 93998 999
22852 1 32445 1 47141 1 64897 1 83021 2 94002 1
22855 1 32480 1 47142 1 64898 1 83026 1 94003 1
22856 1 32482 1 47143 1 64901 2 83030 1 94004 1
22857 1 32484 2 47144 1 64902 100 83033 1 94005 1
22861 1 32486 1 47145 1 64905 1 83036 1 94010 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value22862 1 32488 1 47146 100 64907 1 83037 1 94011 1
22864 1 32491 1 47147 3 64910 3 83045 1 94012 1
22865 1 32501 1 47300 2 64911 2 83050 1 94013 2
22899 999 32503 1 47350 1 64999 999 83051 1 94014 1
22900 3 32504 1 47360 1 65091 1 83055 1 94015 1
22901 3 32505 1 47361 1 65093 1 83060 1 94016 1
22902 13 32506 3 47362 1 65101 1 83065 1 94060 1
22903 3 32507 1 47370 1 65103 1 83068 1 94070 1
22904 3 32540 1 47371 1 65105 1 83069 1 94150 2
22905 3 32550 2 47379 999 65110 1 83070 1 94200 1
22999 999 32551 1 47380 1 65112 1 83071 1 94250 1
23000 1 32552 2 47381 1 65114 1 83080 2 94375 1
23020 1 32553 1 47382 1 65125 1 83088 1 94400 1
23030 2 32554 1 47399 999 65130 1 83090 2 94450 1
23031 1 32555 1 47400 1 65135 1 83150 1 94452 1
23035 1 32556 1 47420 1 65140 1 83491 1 94453 1
23040 1 32557 1 47425 1 65150 1 83497 1 94610 2
23044 1 32560 1 47460 1 65155 1 83498 2 94620 1
23065 1 32561 1 47480 1 65175 1 83499 1 94621 1
23066 1 32562 1 47490 1 65205 1 83500 1 94640 1
23071 3 32601 1 47500 2 65210 1 83505 1 94642 1
23073 3 32604 1 47505 2 65220 1 83516 4 94644 1
23075 1 32606 1 47510 2 65222 1 83518 2 94645 23
23076 1 32607 1 47511 1 65235 1 83519 3 94660 1
23077 1 32608 1 47525 1 65260 1 83520 6 94662 1
23078 1 32609 1 47530 3 65265 1 83525 3 94664 1
23100 1 32650 1 47550 1 65270 1 83527 1 94667 1
23101 1 32651 1 47552 1 65272 1 83528 1 94668 2
23105 1 32652 1 47553 1 65273 1 83540 2 94680 1
23106 1 32653 1 47554 1 65275 1 83550 1 94681 1
23107 1 32654 1 47555 1 65280 1 83570 1 94690 1
23120 1 32655 1 47556 1 65285 1 83582 1 94726 1
23125 1 32656 1 47560 1 65286 1 83586 1 94727 1
23130 1 32658 1 47561 1 65290 1 83593 1 94728 1
23140 1 32659 1 47562 1 65400 1 83605 3 94729 1
23145 1 32661 1 47563 1 65410 1 83615 2 94750 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value23146 1 32662 1 47564 1 65420 1 83625 1 94760 1
23150 1 32663 1 47570 1 65426 1 83630 1 94761 1
23155 1 32664 1 47579 1 65430 1 83631 1 94762 1
23156 1 32665 1 47600 1 65435 1 83632 1 94770 1
23170 1 32666 1 47605 1 65436 1 83633 1 94772 1
23172 1 32667 1 47610 1 65450 1 83634 1 94774 1
23174 1 32668 1 47612 1 65600 1 83655 2 94775 1
23180 1 32669 1 47620 1 65710 1 83661 4 94776 1
23182 1 32670 1 47630 1 65730 1 83662 4 94777 1
23184 1 32671 1 47700 1 65750 1 83663 4 94780 1
23190 1 32672 1 47701 1 65755 1 83664 4 94781 46
23195 1 32673 1 47711 1 65756 1 83670 1 94799 999
23200 1 32674 1 47712 1 65757 1 83690 2 95004 120
23210 1 32701 1 47715 1 65760 1 83695 1 95012 2
23220 1 32800 1 47720 1 65765 1 83698 1 95017 100
23330 1 32810 1 47721 1 65767 1 83700 1 95018 100
23331 1 32815 1 47740 1 65770 1 83701 1 95024 120
23332 1 32820 1 47741 1 65771 1 83704 1 95027 75
23350 1 32850 1 47760 1 65772 1 83718 1 95028 75
23395 1 32851 1 47765 1 65775 1 83719 1 95044 75
23397 1 32852 1 47780 1 65778 1 83721 1 95052 75
23400 1 32853 1 47785 1 65779 1 83727 1 95056 1
23405 2 32854 1 47800 1 65780 1 83735 4 95060 1
23406 2 32855 1 47801 1 65781 1 83775 1 95065 1
23410 1 32856 1 47802 1 65782 1 83785 1 95070 1
23412 1 32900 1 47900 1 65800 1 83788 3 95071 1
23415 1 32905 1 47999 999 65810 1 83789 2 95076 1
23420 1 32906 1 48000 1 65815 1 83805 1 95079 22
23430 1 32940 1 48001 1 65820 1 83825 2 95115 1
23440 1 32960 1 48020 1 65850 1 83835 2 95117 1
23450 1 32997 1 48100 1 65855 1 83840 2 95120 1
23455 1 32998 2 48102 2 65860 1 83857 1 95125 1
23460 1 32999 999 48105 1 65865 1 83858 1 95130 3
23462 1 33010 1 48120 1 65870 1 83861 2 95131 2
23465 1 33011 1 48140 1 65875 1 83864 1 95132 2
23466 1 33015 1 48145 1 65880 1 83866 1 95133 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value23470 1 33020 1 48146 1 65900 1 83872 2 95134 3
23472 1 33025 1 48148 1 65920 1 83873 1 95144 74
23473 1 33030 1 48150 1 65930 1 83874 2 95145 72
23474 1 33031 1 48152 1 66020 1 83876 2 95146 64
23480 1 33050 1 48153 1 66030 1 83880 1 95147 52
23485 1 33120 1 48154 1 66130 1 83883 8 95148 12
23490 1 33130 1 48155 1 66150 1 83885 2 95149 12
23491 1 33140 1 48160 1 66155 1 83887 2 95165 120
23500 1 33141 1 48400 1 66160 1 83915 1 95170 70
23505 1 33202 1 48500 1 66165 1 83916 2 95180 24
23515 1 33203 1 48510 1 66170 1 83918 2 95199 999
23520 1 33206 1 48511 1 66172 1 83919 1 95250 1
23525 1 33207 1 48520 1 66174 1 83921 2 95251 1
23530 1 33208 1 48540 1 66175 1 83925 4 95782 1
23532 1 33210 1 48545 1 66180 1 83930 2 95783 1
23540 1 33211 1 48547 1 66185 1 83935 2 95800 1
23545 1 33212 1 48548 1 66220 1 83937 1 95801 1
23550 1 33213 1 48550 1 66225 1 83945 2 95803 1
23552 1 33214 1 48551 1 66250 1 83950 1 95805 1
23570 1 33215 2 48552 2 66500 1 83951 1 95806 1
23575 1 33216 1 48554 1 66505 1 83970 2 95807 1
23585 1 33217 1 48556 1 66600 1 83986 2 95808 1
23600 1 33218 1 48999 999 66605 1 83987 1 95810 1
23605 1 33220 1 49000 1 66625 1 83992 2 95811 1
23615 1 33221 1 49002 1 66630 1 83993 1 95812 1
23616 1 33222 1 49010 1 66635 1 84022 2 95813 1
23620 1 33223 1 49020 2 66680 1 84030 1 95816 1
23625 1 33224 1 49021 3 66682 1 84035 1 95819 1
23630 1 33225 1 49040 2 66700 1 84060 1 95822 1
23650 1 33226 1 49041 3 66710 1 84061 1 95824 1
23655 1 33227 1 49060 2 66711 1 84066 1 95827 1
23660 1 33228 1 49061 3 66720 1 84075 2 95829 1
23665 1 33229 1 49062 1 66740 1 84078 1 95830 1
23670 1 33230 1 49082 1 66761 1 84080 1 95831 5
23675 1 33231 1 49083 1 66762 1 84081 1 95832 1
23680 1 33233 1 49084 1 66770 1 84085 1 95833 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value23700 1 33234 1 49180 3 66820 1 84087 1 95834 1
23800 1 33235 1 49203 1 66821 1 84100 3 95851 7
23802 1 33236 1 49204 1 66825 1 84105 1 95852 1
23900 1 33237 1 49205 1 66830 1 84106 1 95857 1
23920 1 33238 1 49215 1 66840 1 84110 1 95860 1
23921 1 33240 1 49220 1 66850 1 84112 1 95861 1
23929 999 33241 1 49250 1 66852 1 84119 1 95863 1
23930 1 33243 1 49255 1 66920 1 84120 1 95864 1
23931 1 33244 1 49320 1 66930 1 84126 1 95865 1
23935 1 33249 1 49321 1 66940 1 84127 1 95866 1
24000 1 33250 1 49322 1 66982 1 84132 3 95867 1
24006 1 33251 1 49323 1 66983 1 84133 2 95868 1
24065 1 33254 1 49324 1 66984 1 84134 1 95869 1
24066 1 33255 1 49325 1 66985 1 84135 1 95870 4
24071 3 33256 1 49326 1 66986 1 84138 1 95872 4
24073 3 33257 1 49327 1 66990 1 84140 1 95873 1
24075 1 33258 1 49329 1 66999 1 84143 2 95874 1
24076 1 33259 1 49400 1 67005 1 84144 1 95875 2
24077 1 33261 1 49402 1 67010 1 84145 1 95885 2
24079 1 33262 1 49411 1 67015 1 84146 3 95886 2
24100 1 33263 1 49412 1 67025 1 84150 2 95887 1
24101 1 33264 1 49418 1 67027 1 84152 1 95905 2
24102 1 33265 1 49419 1 67028 1 84153 1 95907 1
24105 1 33266 1 49421 1 67030 1 84154 1 95908 1
24110 1 33282 1 49422 1 67031 1 84155 1 95909 1
24115 1 33284 1 49423 3 67036 1 84156 1 95910 1
24116 1 33300 1 49424 3 67039 1 84157 3 95911 1
24120 1 33305 1 49425 1 67040 1 84160 2 95912 1
24125 1 33310 1 49426 1 67041 1 84163 1 95913 1
24126 1 33315 1 49427 1 67042 1 84165 1 95921 1
24130 1 33320 1 49428 1 67043 1 84166 2 95922 1
24134 1 33321 1 49429 1 67101 1 84181 7 95923 1
24136 1 33322 1 49435 1 67105 1 84182 14 95924 1
24138 1 33330 1 49436 1 67107 1 84202 1 95925 1
24140 1 33332 1 49440 1 67108 1 84203 1 95926 1
24145 1 33335 1 49441 1 67110 1 84206 1 95927 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value24147 1 33361 1 49442 1 67112 1 84207 1 95928 1
24149 1 33362 1 49446 1 67113 1 84210 2 95929 1
24150 1 33363 1 49450 1 67115 1 84220 1 95930 1
24152 1 33364 1 49451 1 67120 1 84228 1 95933 1
24155 1 33365 1 49452 1 67121 1 84233 2 95937 3
24160 1 33367 1 49460 1 67141 1 84234 2 95938 1
24164 1 33368 1 49465 1 67145 1 84235 1 95939 1
24200 1 33369 1 49491 1 67208 1 84238 3 95940 96
24201 1 33400 1 49492 1 67210 1 84244 1 95941 24
24220 1 33401 1 49495 1 67218 1 84252 1 95943 1
24300 1 33403 1 49496 1 67220 1 84255 2 95950 1
24301 2 33404 1 49500 1 67221 1 84260 1 95951 1
24305 4 33405 1 49501 1 67225 1 84270 1 95953 1
24310 5 33406 1 49505 1 67227 1 84275 1 95954 1
24320 2 33410 1 49507 1 67228 1 84285 1 95955 1
24330 1 33411 1 49520 1 67229 1 84295 3 95956 1
24331 1 33412 1 49521 1 67250 1 84300 2 95957 1
24332 1 33413 1 49525 1 67255 1 84302 1 95958 1
24340 1 33414 1 49540 1 67299 1 84305 1 95961 1
24341 1 33415 1 49550 1 67311 1 84307 1 95962 23
24342 1 33416 1 49553 1 67312 1 84311 2 95965 1
24343 1 33417 1 49555 1 67314 1 84315 2 95966 1
24344 1 33420 1 49557 1 67316 1 84375 1 95967 3
24345 1 33422 1 49560 1 67318 1 84376 1 95970 1
24346 1 33425 1 49561 1 67320 2 84377 1 95971 1
24357 1 33426 1 49565 1 67331 1 84378 2 95972 1
24358 1 33427 1 49566 1 67332 1 84379 1 95973 46
24359 1 33430 1 49568 2 67334 1 84392 1 95974 1
24360 1 33460 1 49570 1 67335 1 84402 1 95975 46
24361 1 33463 1 49572 1 67340 2 84403 2 95978 1
24362 1 33464 1 49580 1 67343 1 84425 1 95979 46
24363 1 33465 1 49582 1 67345 1 84430 1 95980 1
24365 1 33468 1 49585 1 67346 1 84431 1 95981 1
24366 1 33470 1 49587 1 67399 1 84432 1 95982 1
24370 1 33471 1 49590 1 67400 1 84436 1 95990 2
24371 1 33472 1 49600 1 67405 1 84437 1 95991 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value24400 1 33474 1 49605 1 67412 1 84439 1 95992 1
24410 1 33475 1 49606 1 67413 1 84442 1 95999 999
24420 1 33476 1 49610 1 67414 1 84443 2 96000 1
24430 1 33478 1 49611 1 67415 1 84445 1 96001 1
24435 1 33496 1 49650 1 67420 1 84446 1 96002 1
24470 1 33500 1 49651 1 67430 1 84449 1 96003 1
24495 1 33501 1 49652 1 67440 1 84450 1 96004 1
24498 1 33502 1 49653 1 67445 1 84460 1 96020 1
24500 1 33503 1 49654 1 67450 1 84466 1 96040 48
24505 1 33504 1 49655 1 67500 1 84478 1 96101 8
24515 1 33505 1 49656 1 67505 1 84479 1 96102 8
24516 1 33506 1 49657 1 67515 1 84480 1 96103 1
24530 1 33507 1 49659 1 67550 1 84481 1 96105 24
24535 1 33508 1 49900 1 67560 1 84482 1 96110 2
24538 1 33510 1 49904 1 67570 1 84484 2 96111 1
24545 1 33511 1 49905 1 67599 1 84485 1 96116 8
24546 1 33512 1 49906 1 67700 1 84488 1 96118 8
24560 1 33513 1 49999 999 67710 1 84490 1 96119 8
24565 1 33514 1 50010 1 67715 1 84510 1 96120 1
24566 1 33516 1 50020 1 67800 1 84512 1 96125 24
24575 1 33517 1 50021 2 67801 1 84520 4 96150 96
24576 1 33518 1 50040 1 67805 1 84525 1 96151 96
24577 1 33519 1 50045 1 67808 1 84540 2 96152 96
24579 1 33521 1 50060 1 67810 1 84545 1 96153 96
24582 1 33522 1 50065 1 67820 1 84550 1 96154 96
24586 1 33523 1 50070 1 67825 1 84560 2 96155 96
24587 1 33530 1 50075 1 67830 1 84577 1 96360 1
24600 1 33533 1 50080 1 67835 1 84578 1 96361 23
24605 1 33534 1 50081 1 67840 1 84580 1 96365 1
24615 1 33535 1 50100 1 67850 1 84583 1 96366 23
24620 1 33536 1 50120 1 67875 1 84585 1 96367 7
24635 1 33542 1 50125 1 67880 1 84586 1 96368 1
24640 1 33545 1 50130 1 67882 1 84588 2 96369 1
24650 1 33548 1 50135 1 67900 1 84590 1 96370 23
24655 1 33572 3 50200 1 67901 1 84591 1 96371 1
24665 1 33600 1 50205 1 67902 1 84597 1 96372 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value24666 1 33602 1 50220 1 67903 1 84600 2 96373 2
24670 1 33606 1 50225 1 67904 1 84620 1 96374 1
24675 1 33608 1 50230 1 67906 1 84630 2 96375 4
24685 1 33610 1 50234 1 67908 1 84681 1 96376 7
24800 1 33611 1 50236 1 67909 1 84702 2 96379 999
24802 1 33612 1 50240 1 67911 1 84703 1 96401 3
24900 1 33615 1 50250 1 67912 1 84704 1 96402 2
24920 1 33617 1 50280 1 67914 1 84830 1 96405 1
24925 1 33619 1 50290 1 67915 1 84999 999 96406 1
24930 1 33620 1 50300 1 67916 1 85002 1 96409 1
24931 1 33621 1 50320 1 67917 1 85004 2 96411 3
24935 1 33622 1 50323 1 67921 1 85007 1 96413 1
24940 1 33641 1 50325 1 67922 1 85008 1 96415 23
24999 1 33645 1 50327 3 67923 1 85009 1 96416 1
25000 1 33647 1 50328 3 67924 1 85013 2 96417 2
25001 1 33660 1 50329 2 67930 1 85014 2 96420 2
25020 1 33665 1 50340 1 67935 1 85018 2 96422 2
25023 1 33670 1 50360 1 67938 1 85025 2 96423 23
25024 1 33675 1 50365 1 67950 1 85027 2 96425 1
25025 1 33676 1 50370 1 67961 1 85032 3 96440 1
25028 1 33677 1 50380 1 67966 1 85041 2 96446 1
25031 1 33681 1 50382 1 67971 1 85044 1 96450 1
25035 1 33684 1 50384 1 67973 1 85045 1 96521 2
25040 1 33688 1 50385 1 67974 1 85046 1 96522 1
25065 1 33690 1 50386 1 67975 1 85048 2 96523 1
25066 1 33692 1 50387 1 67999 1 85049 2 96542 1
25071 3 33694 1 50389 1 68020 1 85055 1 96549 999
25073 3 33697 1 50390 1 68040 1 85060 1 96567 1
25075 1 33702 1 50391 1 68100 1 85097 2 96570 1
25076 1 33710 1 50392 1 68110 1 85130 2 96571 94
25077 1 33720 1 50393 1 68115 1 85170 1 96900 1
25078 1 33722 1 50394 1 68130 1 85175 1 96902 1
25085 1 33724 1 50395 1 68135 1 85210 2 96904 1
25100 1 33726 1 50396 1 68200 1 85220 2 96910 1
25101 1 33730 1 50398 1 68320 1 85230 2 96912 1
25105 1 33732 1 50400 1 68325 1 85240 2 96913 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value25107 1 33735 1 50405 1 68326 1 85244 2 96920 1
25109 1 33736 1 50500 1 68328 1 85245 2 96921 1
25110 1 33737 1 50520 1 68330 1 85246 2 96922 1
25111 1 33750 1 50525 1 68335 1 85247 2 96999 999
25112 1 33755 1 50526 1 68340 1 85250 2 97001 1
25115 1 33762 1 50540 1 68360 1 85260 2 97002 1
25116 1 33764 1 50541 1 68362 1 85270 2 97003 1
25118 1 33766 1 50542 1 68371 1 85280 2 97004 1
25119 1 33767 1 50543 1 68399 1 85290 2 97005 1
25120 1 33768 1 50544 1 68400 1 85291 2 97006 1
25125 1 33770 1 50545 1 68420 1 85292 2 97010 1
25126 1 33771 1 50546 1 68440 2 85293 2 97012 1
25130 1 33774 1 50547 1 68500 1 85300 2 97014 1
25135 1 33775 1 50548 1 68505 1 85301 2 97016 1
25136 1 33776 1 50549 1 68510 1 85302 2 97018 1
25145 1 33777 1 50551 1 68520 1 85303 2 97022 1
25150 1 33778 1 50553 1 68525 1 85305 2 97024 1
25151 1 33779 1 50555 1 68530 1 85306 2 97026 1
25170 1 33780 1 50557 1 68540 1 85307 2 97028 1
25210 2 33781 1 50561 1 68550 1 85335 2 97032 4
25215 1 33782 1 50562 1 68700 1 85337 1 97033 4
25230 1 33783 1 50570 1 68705 2 85345 2 97034 4
25240 1 33786 1 50572 1 68720 1 85347 12 97035 4
25246 1 33788 1 50574 1 68745 1 85348 1 97036 4
25248 1 33800 1 50575 1 68750 1 85360 1 97039 999
25250 1 33802 1 50576 1 68760 2 85362 2 97110 4
25251 1 33803 1 50580 1 68761 2 85366 2 97112 4
25259 1 33813 1 50590 1 68770 1 85370 2 97113 4
25260 10 33814 1 50592 1 68801 2 85378 2 97116 4
25263 12 33820 1 50593 1 68810 1 85379 2 97124 4
25265 5 33822 1 50600 1 68811 1 85380 2 97139 999
25270 12 33824 1 50605 1 68815 1 85384 2 97140 4
25272 15 33840 1 50610 1 68816 1 85385 1 97150 1
25274 9 33845 1 50620 1 68840 1 85390 3 97530 4
25275 1 33851 1 50630 1 68850 1 85396 1 97532 4
25280 11 33852 1 50650 1 68899 1 85397 2 97533 4
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value25290 13 33853 1 50660 1 69000 1 85400 2 97535 4
25295 9 33860 1 50684 1 69005 1 85410 2 97537 4
25300 1 33863 1 50686 2 69020 1 85415 2 97542 4
25301 1 33864 1 50688 2 69090 2 85420 2 97545 1
25310 3 33870 1 50690 2 69100 3 85421 2 97546 22
25312 7 33875 1 50700 1 69105 1 85441 1 97597 1
25315 1 33877 1 50715 1 69110 1 85445 1 97598 5
25316 1 33880 1 50722 1 69120 1 85460 1 97602 1
25320 1 33881 1 50725 1 69140 1 85461 1 97605 1
25332 1 33883 1 50727 1 69145 1 85475 1 97606 1
25335 1 33884 3 50728 1 69150 1 85520 14 97750 4
25337 1 33886 1 50740 1 69155 1 85525 2 97755 4
25350 1 33889 1 50750 1 69200 1 85530 1 97760 4
25355 1 33891 1 50760 1 69205 1 85536 1 97761 4
25360 1 33910 1 50770 1 69210 1 85540 1 97762 4
25365 1 33915 1 50780 1 69220 1 85547 1 97799 999
25370 1 33916 1 50782 1 69222 1 85549 1 97802 96
25375 1 33917 1 50783 1 69300 1 85555 1 97803 96
25390 1 33920 1 50785 1 69310 1 85557 1 97804 48
25391 1 33922 1 50800 1 69320 1 85576 19 97810 1
25392 1 33924 1 50810 1 69399 999 85597 1 97811 95
25393 1 33925 1 50815 1 69400 1 85598 1 97813 1
25394 1 33926 1 50820 1 69401 1 85610 2 97814 95
25400 1 33930 1 50825 1 69405 1 85611 2 98925 1
25405 1 33933 1 50830 1 69420 1 85612 1 98926 1
25415 1 33935 1 50840 1 69421 1 85613 1 98927 1
25420 1 33940 1 50845 1 69424 1 85635 1 98928 1
25425 1 33944 1 50860 1 69433 1 85651 1 98929 1
25426 1 33945 1 50900 1 69436 1 85652 1 98940 1
25430 1 33960 1 50920 2 69440 1 85660 1 98941 1
25431 1 33961 1 50930 2 69450 1 85670 2 98942 1
25440 1 33967 1 50940 1 69501 1 85675 1 98943 1
25441 1 33968 1 50945 1 69502 1 85705 1 98960 48
25442 1 33970 1 50947 1 69505 1 85730 2 98961 48
25443 1 33971 1 50948 1 69511 1 85732 4 98962 48
25444 1 33973 1 50949 1 69530 1 85810 2 98966 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value25445 1 33974 1 50951 1 69535 1 85999 999 98967 1
25446 1 33975 1 50953 1 69540 1 86000 15 98968 1
25447 1 33976 1 50955 1 69550 1 86001 75 98969 1
25449 1 33977 1 50957 1 69552 1 86003 75 99000 2
25450 1 33978 1 50961 1 69554 1 86005 6 99001 3
25455 1 33979 2 50970 1 69601 1 86021 1 99002 2
25490 1 33980 2 50972 1 69602 1 86022 1 99024 1
25491 1 33981 2 50974 1 69603 1 86023 2 99026 24
25492 1 33982 1 50976 1 69604 1 86038 1 99027 24
25500 1 33983 1 50980 1 69605 1 86039 1 99050 1
25505 1 33990 1 51020 1 69610 1 86060 1 99051 1
25515 1 33991 1 51030 1 69620 1 86063 1 99053 1
25520 1 33992 1 51040 1 69631 1 86077 1 99056 1
25525 1 33993 1 51045 2 69632 1 86078 1 99058 1
25526 1 33999 999 51050 1 69633 1 86079 1 99060 1
25530 1 34001 1 51060 1 69635 1 86140 1 99070 1
25535 1 34051 1 51065 1 69636 1 86141 1 99071 1
25545 1 34101 1 51080 2 69637 1 86146 3 99075 5
25560 1 34111 1 51100 1 69641 1 86147 4 99078 18
25565 1 34151 1 51101 1 69642 1 86148 1 99080 3
25574 1 34201 1 51102 1 69643 1 86152 1 99082 1
25575 1 34203 1 51500 1 69644 1 86153 1 99090 2
25600 1 34401 1 51520 1 69645 1 86155 1 99091 1
25605 1 34421 1 51525 1 69646 1 86156 1 99143 1
25606 1 34451 1 51530 1 69650 1 86157 1 99144 1
25607 1 34471 1 51535 1 69660 1 86160 4 99145 94
25608 1 34490 1 51550 1 69661 1 86161 3 99148 1
25609 1 34501 1 51555 1 69662 1 86162 1 99149 1
25622 1 34502 1 51565 1 69666 1 86171 2 99150 94
25624 1 34510 1 51570 1 69667 1 86185 100 99170 1
25628 1 34520 1 51575 1 69670 1 86200 1 99172 1
25630 1 34530 1 51580 1 69676 1 86215 1 99173 1
25635 1 34800 1 51585 1 69700 1 86225 1 99174 1
25645 7 34802 1 51590 1 69710 1 86226 1 99175 1
25650 1 34803 1 51595 1 69711 1 86235 8 99183 1
25651 1 34804 1 51596 1 69714 1 86243 1 99190 24
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value25652 1 34805 1 51597 1 69715 1 86255 3 99191 1
25660 1 34806 1 51600 1 69717 1 86256 6 99192 1
25670 1 34808 1 51605 1 69718 1 86277 1 99195 2
25671 1 34812 1 51610 1 69720 1 86280 1 99199 999
25675 1 34813 1 51700 1 69725 1 86294 1 99201 1
25676 1 34820 1 51701 2 69740 1 86300 2 99202 1
25680 1 34825 2 51702 2 69745 1 86301 1 99203 1
25685 1 34826 4 51703 2 69799 1 86304 1 99204 1
25690 1 34830 1 51705 1 69801 1 86305 1 99205 1
25695 1 34831 1 51710 1 69805 1 86308 1 99211 1
25800 1 34832 1 51715 1 69806 1 86309 1 99212 1
25805 1 34833 1 51720 1 69820 1 86310 1 99213 1
25810 1 34834 1 51725 1 69840 1 86316 3 99214 1
25820 1 34900 1 51726 1 69905 1 86317 62 99215 1
25825 1 35001 1 51727 1 69910 1 86318 1 99217 1
25830 1 35002 1 51728 1 69915 1 86320 1 99218 1
25900 1 35005 1 51729 1 69930 1 86325 2 99219 1
25905 1 35011 1 51736 1 69949 1 86327 1 99220 1
25907 1 35013 1 51741 1 69950 1 86329 10 99221 1
25909 1 35021 1 51784 1 69955 1 86331 17 99222 1
25915 1 35022 1 51785 1 69960 1 86332 1 99223 1
25920 1 35045 1 51792 1 69970 1 86334 1 99224 1
25922 1 35081 1 51797 1 69979 1 86335 2 99225 1
25924 1 35082 1 51798 1 69990 1 86336 1 99226 1
25927 1 35091 1 51800 1 70010 1 86337 1 99231 1
25929 1 35092 1 51820 1 70015 1 86340 1 99232 1
25931 1 35102 1 51840 1 70030 1 86341 1 99233 1
25999 1 35103 1 51841 1 70100 1 86343 1 99234 1
26010 3 35111 1 51845 1 70110 1 86344 1 99235 1
26011 3 35112 1 51860 1 70120 1 86352 1 99236 1
26020 1 35121 1 51865 1 70130 1 86353 5 99238 1
26025 1 35122 1 51880 1 70134 1 86355 1 99239 1
26030 1 35131 1 51900 1 70140 1 86356 15 99241 1
26034 2 35132 1 51920 1 70150 1 86357 1 99242 1
26035 3 35141 1 51925 1 70160 1 86359 1 99243 1
26037 1 35142 1 51940 1 70170 1 86360 1 99244 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value26040 1 35151 1 51960 1 70190 1 86361 1 99245 1
26045 1 35152 1 51980 1 70200 1 86367 1 99251 1
26055 1 35180 2 51990 1 70210 1 86376 2 99252 1
26060 1 35182 2 51992 1 70220 1 86378 1 99253 1
26070 1 35184 2 51999 999 70240 1 86382 3 99254 1
26075 1 35188 2 52000 1 70250 1 86384 1 99255 1
26080 2 35189 1 52001 1 70260 1 86386 1 99281 1
26100 1 35190 2 52005 1 70300 1 86403 2 99282 1
26105 1 35201 1 52007 1 70310 1 86406 2 99283 1
26110 2 35206 1 52010 1 70320 1 86430 2 99284 1
26111 8 35207 1 52204 1 70328 1 86431 2 99285 1
26113 7 35211 1 52214 1 70330 1 86480 1 99288 1
26115 2 35216 1 52224 1 70332 1 86481 1 99291 1
26116 2 35221 1 52234 1 70336 1 86485 1 99292 46
26117 2 35226 1 52235 1 70350 1 86486 2 99304 1
26118 1 35231 1 52240 1 70355 1 86490 1 99305 1
26121 1 35236 1 52250 1 70360 1 86510 1 99306 1
26123 1 35241 1 52260 1 70370 1 86580 1 99307 1
26125 1 35246 1 52265 1 70371 1 86590 1 99308 1
26130 1 35251 1 52270 1 70373 1 86592 2 99309 1
26135 1 35256 1 52275 1 70380 2 86593 2 99310 1
26140 1 35261 1 52276 1 70390 2 86602 3 99315 1
26145 3 35266 1 52277 1 70450 3 86603 2 99316 1
26160 2 35271 1 52281 1 70460 1 86606 16 99318 1
26170 9 35276 1 52282 1 70470 2 86609 53 99324 1
26180 3 35281 1 52283 1 70480 1 86611 8 99325 1
26185 1 35286 1 52285 1 70481 1 86612 2 99326 1
26200 4 35301 1 52287 1 70482 1 86615 4 99327 1
26205 2 35302 1 52290 1 70486 1 86617 2 99328 1
26210 8 35303 1 52300 1 70487 1 86618 2 99334 1
26215 2 35304 1 52301 1 70488 1 86619 2 99335 1
26230 3 35305 1 52305 1 70490 1 86622 6 99336 1
26235 4 35306 2 52310 1 70491 1 86625 2 99337 1
26236 3 35311 1 52315 2 70492 1 86628 3 99339 1
26250 2 35321 1 52317 1 70496 1 86631 10 99340 1
26260 2 35331 1 52318 1 70498 1 86632 3 99341 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value26262 2 35341 1 52320 1 70540 1 86635 9 99342 1
26320 8 35351 1 52325 1 70542 1 86638 10 99343 1
26340 3 35355 1 52327 1 70543 1 86641 2 99344 1
26341 1 35361 1 52330 1 70544 1 86644 1 99345 1
26350 3 35363 1 52332 1 70545 1 86645 1 99347 1
26352 3 35371 1 52334 1 70546 1 86648 2 99348 1
26356 3 35372 1 52341 1 70547 1 86651 2 99349 1
26357 3 35390 2 52342 1 70548 1 86652 2 99350 1
26358 3 35400 1 52343 1 70549 1 86653 2 99354 1
26370 8 35450 1 52344 1 70551 1 86654 2 99355 46
26372 4 35452 1 52345 1 70552 1 86658 37 99356 1
26373 2 35458 1 52346 1 70553 1 86663 2 99357 46
26390 3 35460 1 52351 1 70554 1 86664 2 99358 1
26392 3 35471 1 52352 1 70555 1 86665 2 99359 46
26410 2 35472 1 52353 1 70557 1 86666 12 99360 1
26412 2 35475 1 52354 1 70558 1 86668 2 99363 1
26415 2 35476 1 52355 1 70559 1 86671 2 99364 1
26416 2 35500 2 52400 1 71010 4 86674 3 99366 1
26418 2 35501 1 52402 1 71015 2 86677 3 99367 1
26420 2 35506 1 52450 1 71020 4 86682 4 99368 1
26426 2 35508 1 52500 1 71021 1 86684 2 99374 1
26428 2 35509 1 52601 1 71022 1 86687 2 99375 1
26432 2 35510 1 52630 1 71023 2 86688 2 99377 1
26433 2 35511 1 52640 1 71030 2 86689 2 99378 1
26434 3 35512 1 52647 1 71034 1 86692 2 99379 1
26437 4 35515 1 52648 1 71035 2 86694 2 99380 1
26440 3 35516 1 52649 1 71100 1 86695 2 99381 1
26442 3 35518 1 52700 1 71101 1 86696 2 99382 1
26445 2 35521 1 53000 1 71110 1 86698 3 99383 1
26449 2 35522 1 53010 1 71111 1 86701 2 99384 1
26450 52 35523 1 53020 1 71120 1 86702 2 99385 1
26455 3 35525 1 53025 1 71130 1 86703 1 99386 1
26460 2 35526 1 53040 1 71250 1 86704 1 99387 1
26471 1 35531 1 53060 1 71260 1 86705 1 99391 1
26474 1 35533 1 53080 1 71270 1 86706 2 99392 1
26476 2 35535 1 53085 1 71275 1 86707 2 99393 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value26477 2 35536 1 53200 1 71550 1 86708 1 99394 1
26478 3 35537 1 53210 1 71551 1 86709 1 99395 1
26479 3 35538 1 53215 1 71552 1 86710 12 99396 1
26480 10 35539 1 53220 1 71555 1 86711 100 99397 1
26483 10 35540 1 53230 1 72010 1 86713 3 99401 1
26485 8 35556 1 53235 1 72020 4 86717 100 99402 1
26489 100 35558 1 53240 1 72040 3 86720 2 99403 1
26490 10 35560 1 53250 1 72050 1 86723 2 99404 1
26492 100 35563 1 53260 1 72052 1 86727 2 99406 1
26494 2 35565 1 53265 1 72069 1 86729 100 99407 1
26496 2 35566 1 53270 1 72070 1 86732 2 99408 1
26497 2 35570 1 53275 1 72072 1 86735 2 99409 1
26498 2 35571 1 53400 1 72074 1 86738 2 99411 1
26499 1 35572 2 53405 1 72080 1 86741 2 99412 1
26500 4 35583 1 53410 1 72090 1 86744 2 99420 1
26502 2 35585 1 53415 1 72100 1 86747 2 99429 1
26508 1 35587 1 53420 1 72110 1 86750 4 99441 1
26510 100 35600 2 53425 1 72114 1 86753 3 99442 1
26516 1 35601 1 53430 1 72120 1 86756 2 99443 1
26517 1 35606 1 53431 1 72125 1 86757 12 99444 1
26518 1 35612 1 53440 1 72126 1 86759 2 99450 1
26520 1 35616 1 53442 1 72127 1 86762 2 99455 1
26525 2 35621 1 53444 1 72128 1 86765 2 99456 1
26530 1 35623 1 53445 1 72129 1 86768 5 99460 1
26531 1 35626 1 53446 1 72130 1 86771 2 99461 1
26535 2 35631 1 53447 1 72131 1 86774 2 99462 1
26536 2 35632 1 53448 1 72132 1 86777 2 99463 1
26540 6 35633 1 53449 1 72133 1 86778 2 99464 1
26541 2 35634 1 53450 1 72141 1 86780 2 99465 1
26542 2 35636 1 53460 1 72142 1 86784 2 99466 1
26545 2 35637 1 53500 1 72146 1 86787 2 99467 46
26546 1 35638 1 53502 1 72147 1 86788 2 99468 1
26548 2 35642 1 53505 1 72148 1 86789 2 99469 1
26550 1 35645 1 53510 1 72149 1 86790 2 99471 1
26551 1 35646 1 53515 1 72156 1 86793 2 99472 1
26553 1 35647 1 53520 1 72157 1 86800 1 99475 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List
Code Value Code Value Code Value Code Value Code Value Code Value26554 1 35650 1 53600 1 72158 1 86803 2 99476 1
26555 2 35654 1 53601 1 72159 1 86804 1 99477 1
26556 2 35656 1 53605 1 72170 1 86805 8 99478 1
26560 2 35661 1 53620 1 72190 1 86806 4 99479 1
26561 2 35663 1 53621 1 72191 1 86807 2 99480 1
26562 2 35665 1 53660 1 72192 1 86808 1 99485 1
26565 1 35666 1 53661 1 72193 1 86812 1 99486 47
26567 1 35671 1 53665 1 72194 1 86813 3 99487 1
26568 1 35681 2 53850 1 72195 1 86816 1 99488 1
26580 1 35682 1 53852 1 72196 1 86817 1 99489 1
26587 1 35683 1 53855 1 72197 1 86821 3 99495 1
26590 1 35685 2 53860 1 72198 1 86822 3 99496 1
26591 6 35686 1 53899 999 72200 1 86825 1 99499 1
26593 6 35691 1 54000 1 72202 1 86826 100 99500 1
26596 1 35693 1 54001 1 72220 1 86828 100 99501 1
26600 10 35694 1 54015 1 72240 1 86829 100 99502 1
26605 10 35695 1 54050 1 72255 1 86830 100 99503 1
26607 10 35697 2 54055 1 72265 1 86831 100 99504 1
26608 10 35700 2 54056 1 72270 1 86832 100 99505 1
26615 10 35701 1 54057 1 72275 3 86833 100 99506 1
26641 1 35721 1 54060 1 72285 19 86834 100 99507 1
26645 1 35741 1 54065 1 72291 24 86835 100 99509 1
26650 1 35761 1 54100 3 72292 3 86849 999 99510 1
26665 1 35800 2 54105 2 72295 5 86850 3 99511 1
26670 8 35820 2 54110 1 73000 1 86860 2 99512 1
26675 8 35840 2 54111 1 73010 1 86870 3 99600 999
26676 8 35860 2 54112 1 73020 1 86880 2 99601 12
26685 8 35870 1 54115 1 73030 1 86885 3 99602 22
26686 8 35875 2 54120 1 73040 1 86886 3 99605 1
26700 1 35876 2 54125 1 73050 1 86890 1 99606 1
26705 1 35879 1 73060 1 86891 2 99607 95
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2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code Value
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA0021 100 D2664 32 E1031 1 J2370 999 L3460 2 S0034 999
A0080 100 D2710 32 E1035 1 J2400 999 L3465 2 S0039 999
A0090 100 D2712 32 E1036 1 J2405 999 L3470 2 S0040 999
A0100 100 D2720 32 E1037 1 J2410 999 L3480 2 S0073 999
A0110 100 D2721 32 E1038 1 J2425 999 L3485 2 S0074 999
A0120 100 D2722 32 E1039 1 J2426 999 L3500 2 S0077 999
A0130 100 D2740 32 E1050 1 J2430 999 L3510 2 S0078 999
A0140 100 D2750 32 E1060 1 J2440 999 L3520 2 S0080 999
A0160 100 D2751 32 E1070 1 J2460 999 L3530 2 S0081 999
A0170 100 D2752 32 E1083 1 J2469 999 L3540 2 S0088 999
A0180 100 D2780 32 E1084 1 J2501 999 L3550 2 S0090 999
A0190 100 D2781 32 E1085 1 J2503 999 L3560 2 S0091 999
A0200 100 D2782 32 E1086 1 J2504 999 L3570 2 S0092 999
A0210 100 D2783 32 E1087 1 J2505 999 L3580 2 S0093 999
A0225 100 D2790 32 E1088 1 J2507 999 L3590 2 S0104 999
A0380 100 D2791 32 E1089 1 J2510 999 L3595 2 S0106 999
A0382 100 D2792 32 E1090 1 J2513 999 L3600 2 S0108 999
A0384 100 D2794 32 E1092 1 J2515 999 L3610 2 S0109 999
A0390 100 D2799 32 E1093 1 J2540 999 L3620 2 S0117 999
A0392 100 D2910 32 E1100 1 J2543 999 L3630 2 S0119 999
A0394 100 D2915 32 E1110 1 J2545 999 L3640 1 S0122 999
A0396 100 D2920 32 E1130 1 J2550 999 L3649 999 S0126 999
A0398 100 D2929 20 E1140 1 J2560 999 L3650 1 S0128 999
A0420 48 D2930 20 E1150 1 J2562 999 L3660 1 S0132 999
A0422 100 D2931 32 E1160 1 J2590 999 L3670 1 S0136 999
A0424 100 D2932 32 E1161 1 J2597 999 L3671 1 S0137 999
A0425 100 D2933 32 E1170 1 J2650 999 L3674 1 S0138 999
A0426 100 D2934 32 E1171 1 J2670 999 L3675 1 S0139 999
A0427 100 D2940 32 E1172 1 J2675 999 L3677 1 S0140 999
A0428 100 D2950 32 E1180 1 J2680 999 L3702 2 S0142 999
A0429 100 D2951 32 E1190 1 J2690 999 L3710 2 S0145 999
A0430 100 D2952 32 E1195 1 J2700 999 L3720 2 S0148 999
A0431 100 D2953 32 E1200 1 J2710 999 L3730 2 S0155 999
A0432 100 D2954 32 E1220 1 J2720 999 L3740 2 S0156 999
A0433 100 D2955 32 E1221 1 J2724 999 L3760 2 S0157 999
A0434 100 D2957 32 E1222 1 J2725 999 L3762 2 S0160 999
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA0435 100 D2960 32 E1223 1 J2730 999 L3763 2 S0164 999
A0436 100 D2961 32 E1224 1 J2760 999 L3764 2 S0166 999
A0888 100 D2962 32 E1225 1 J2765 999 L3765 2 S0169 999
A0998 100 D2970 32 E1226 1 J2770 999 L3766 2 S0170 999
A0999 999 D2971 32 E1227 2 J2778 999 L3806 2 S0171 999
A4206 10 D2975 32 E1228 1 J2780 999 L3807 2 S0172 999
A4207 5 D2980 32 E1229 999 J2783 999 L3808 2 S0174 999
A4208 5 D2981 32 E1230 1 J2785 999 L3891 4 S0175 999
A4209 9 D2982 32 E1231 1 J2788 999 L3900 2 S0176 999
A4210 6 D2983 32 E1232 1 J2790 999 L3901 2 S0177 999
A4211 75 D2990 32 E1233 1 J2791 999 L3904 2 S0178 999
A4212 2 D2999 999 E1234 1 J2792 999 L3905 2 S0179 999
A4213 13 D3110 32 E1235 1 J2793 999 L3906 2 S0182 999
A4215 14 D3120 32 E1236 1 J2794 999 L3908 2 S0183 999
A4216 999 D3220 32 E1237 1 J2795 999 L3912 2 S0187 999
A4217 999 D3221 32 E1238 1 J2796 999 L3913 2 S0189 999
A4218 999 D3222 32 E1239 999 J2800 999 L3915 2 S0190 999
A4220 1 D3230 12 E1240 1 J2805 999 L3917 2 S0191 999
A4221 1 D3240 8 E1250 1 J2810 999 L3919 2 S0194 999
A4222 75 D3310 12 E1260 1 J2820 999 L3921 2 S0195 999
A4223 75 D3320 8 E1270 1 J2850 999 L3923 2 S0197 3
A4230 75 D3330 12 E1280 1 J2910 999 L3925 1 S0199 1
A4231 75 D3331 32 E1285 1 J2916 999 L3927 1 S0201 1
A4232 75 D3332 32 E1290 1 J2920 999 L3929 2 S0207 2
A4233 46 D3333 32 E1295 1 J2930 999 L3931 2 S0208 2
A4234 3 D3346 12 E1296 1 J2940 999 L3933 1 S0209 74
A4235 2 D3347 8 E1297 1 J2941 999 L3935 1 S0215 74
A4236 2 D3348 12 E1298 1 J2950 999 L3956 4 S0220 48
A4244 12 D3351 1 E1300 1 J2993 999 L3960 1 S0221 24
A4245 75 D3352 1 E1310 1 J2995 999 L3961 1 S0250 100
A4246 2 D3353 1 E1353 1 J2997 999 L3962 1 S0255 100
A4247 8 D3354 32 E1354 1 J3000 999 L3967 1 S0257 1
A4248 60 D3410 12 E1355 1 J3010 999 L3971 1 S0260 1
A4250 3 D3421 1 E1356 2 J3030 999 L3973 1 S0265 96
A4252 60 D3425 1 E1357 100 J3070 999 L3975 1 S0270 1
A4253 1 D3426 18 E1358 100 J3095 999 L3976 1 S0271 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA4255 1 D3430 32 E1372 1 J3101 999 L3977 1 S0272 1
A4256 2 D3450 32 E1390 1 J3105 999 L3978 1 S0273 1
A4257 100 D3460 32 E1391 1 J3110 999 L3980 2 S0274 1
A4258 1 D3470 32 E1392 1 J3120 999 L3982 2 S0280 1
A4259 1 D3910 32 E1399 999 J3130 999 L3984 2 S0281 1
A4261 100 D3920 32 E1405 1 J3140 999 L3995 2 S0302 2
A4262 2 D3950 32 E1406 1 J3150 999 L3999 999 S0310 100
A4263 2 D3999 999 E1500 1 J3230 999 L4000 1 S0315 1
A4264 1 D4210 4 E1510 1 J3240 999 L4002 12 S0316 1
A4265 6 D4211 4 E1520 1 J3243 999 L4010 2 S0317 1
A4266 1 D4212 32 E1530 1 J3246 999 L4020 2 S0320 1
A4267 48 D4230 4 E1540 1 J3250 999 L4030 2 S0340 1
A4268 12 D4231 4 E1550 1 J3260 999 L4040 2 S0341 1
A4269 12 D4240 4 E1560 1 J3262 999 L4045 2 S0342 1
A4270 1 D4241 4 E1570 1 J3265 999 L4050 2 S0353 1
A4280 100 D4245 32 E1575 10 J3280 999 L4055 2 S0354 100
A4281 100 D4249 32 E1580 1 J3285 999 L4060 2 S0390 1
A4282 100 D4260 4 E1590 1 J3300 999 L4070 2 S0395 2
A4283 100 D4261 4 E1592 1 J3301 999 L4080 2 S0400 100
A4284 100 D4263 4 E1594 1 J3302 999 L4090 2 S0500 24
A4285 100 D4264 7 E1600 1 J3303 999 L4100 2 S0504 100
A4286 100 D4265 1 E1610 1 J3305 999 L4110 2 S0506 100
A4290 5 D4266 6 E1615 1 J3310 999 L4130 2 S0508 100
A4300 2 D4267 4 E1620 1 J3315 999 L4205 96 S0510 100
A4301 2 D4268 32 E1625 1 J3320 999 L4210 6 S0512 100
A4305 75 D4270 1 E1630 1 J3350 999 L4350 2 S0514 100
A4306 7 D4273 32 E1632 100 J3355 999 L4360 2 S0515 4
A4310 75 D4274 1 E1634 30 J3357 999 L4370 2 S0516 100
A4311 2 D4275 1 E1635 1 J3360 999 L4386 2 S0518 100
A4312 31 D4276 32 E1636 100 J3364 999 L4392 2 S0580 6
A4313 30 D4277 1 E1637 10 J3365 999 L4394 2 S0581 100
A4314 2 D4278 31 E1639 1 J3370 999 L4396 2 S0590 100
A4315 3 D4320 32 E1699 999 J3385 999 L4398 2 S0592 1
A4316 4 D4321 32 E1700 1 J3396 999 L4631 2 S0595 100
A4320 10 D4341 4 E1701 100 J3400 999 L5000 2 S0596 2
A4321 5 D4342 4 E1702 100 J3410 999 L5010 2 S0601 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA4322 62 D4355 1 E1800 2 J3411 999 L5020 2 S0610 1
A4326 50 D4381 32 E1801 2 J3415 999 L5050 2 S0612 1
A4327 2 D4910 1 E1802 2 J3420 999 L5060 2 S0613 1
A4328 4 D4920 1 E1805 2 J3430 999 L5100 2 S0618 1
A4330 100 D4999 999 E1806 2 J3465 999 L5105 2 S0620 1
A4331 14 D5110 1 E1810 2 J3470 999 L5150 2 S0621 1
A4332 75 D5120 1 E1811 2 J3471 999 L5160 2 S0622 1
A4333 50 D5130 1 E1812 2 J3472 999 L5200 2 S0630 3
A4334 35 D5140 1 E1815 2 J3473 999 L5210 2 S0800 2
A4335 999 D5211 1 E1816 2 J3475 999 L5220 2 S0810 2
A4336 100 D5212 1 E1818 2 J3480 999 L5230 2 S0812 2
A4338 7 D5213 1 E1820 2 J3485 999 L5250 2 S1001 13
A4340 4 D5214 1 E1821 1 J3486 999 L5270 2 S1002 5
A4344 60 D5225 1 E1825 1 J3487 999 L5280 2 S1015 12
A4346 12 D5226 1 E1830 2 J3488 999 L5301 2 S1016 2
A4349 75 D5281 1 E1831 1 J3490 999 L5312 2 S1030 1
A4351 75 D5410 1 E1840 2 J3520 999 L5321 2 S1031 100
A4352 75 D5411 1 E1841 2 J3530 999 L5331 2 S1040 1
A4353 75 D5421 1 E1902 1 J3535 999 L5341 2 S1090 999
A4354 2 D5422 1 E2000 1 J3570 999 L5400 2 S2053 1
A4355 4 D5510 2 E2100 1 J3590 999 L5410 2 S2054 1
A4356 1 D5520 32 E2101 1 J7030 4 L5420 2 S2055 1
A4357 8 D5610 2 E2120 1 J7040 4 L5430 2 S2060 1
A4358 10 D5620 2 E2201 1 J7042 6 L5450 2 S2061 1
A4360 100 D5630 32 E2202 1 J7050 6 L5460 2 S2065 1
A4361 10 D5640 32 E2203 1 J7060 5 L5500 2 S2066 1
A4362 75 D5650 32 E2204 1 J7070 4 L5505 2 S2067 1
A4363 75 D5660 32 E2205 2 J7100 100 L5510 2 S2068 1
A4364 50 D5670 1 E2206 2 J7110 2 L5520 2 S2070 1
A4366 60 D5671 1 E2207 2 J7120 3 L5530 2 S2079 1
A4367 5 D5710 1 E2208 1 J7131 999 L5535 2 S2080 1
A4368 60 D5711 1 E2209 2 J7178 999 L5540 2 S2083 1
A4369 75 D5720 1 E2210 16 J7180 999 L5560 2 S2095 100
A4371 9 D5721 1 E2211 2 J7183 999 L5570 2 S2102 1
A4372 20 D5730 1 E2212 2 J7185 999 L5580 2 S2103 1
A4373 75 D5731 1 E2213 2 J7186 999 L5585 2 S2107 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA4375 60 D5740 1 E2214 2 J7187 999 L5590 2 S2112 1
A4376 60 D5741 1 E2215 2 J7189 999 L5595 2 S2115 2
A4377 50 D5750 1 E2216 2 J7190 999 L5600 2 S2117 1
A4378 60 D5751 1 E2217 2 J7191 999 L5610 2 S2118 1
A4379 100 D5760 1 E2218 2 J7192 999 L5611 2 S2120 100
A4380 100 D5761 1 E2219 2 J7193 999 L5613 2 S2140 1
A4381 100 D5810 1 E2220 2 J7194 999 L5614 2 S2142 1
A4382 100 D5811 1 E2221 2 J7195 999 L5616 2 S2150 1
A4383 100 D5820 1 E2222 2 J7196 999 L5617 2 S2152 1
A4384 100 D5821 1 E2224 2 J7197 999 L5618 4 S2202 100
A4385 70 D5850 1 E2225 2 J7198 999 L5620 7 S2205 1
A4387 100 D5851 1 E2226 2 J7199 999 L5622 4 S2206 1
A4388 70 D5860 2 E2227 2 J7300 1 L5624 6 S2207 1
A4389 60 D5861 2 E2228 2 J7302 1 L5626 100 S2208 1
A4390 75 D5862 32 E2230 1 J7303 12 L5628 2 S2209 1
A4391 60 D5867 32 E2231 1 J7304 18 L5629 2 S2225 1
A4392 60 D5875 32 E2291 2 J7306 1 L5630 2 S2230 1
A4393 60 D5899 999 E2292 100 J7307 1 L5631 2 S2235 1
A4394 72 D5911 100 E2293 1 J7308 999 L5632 2 S2260 1
A4395 100 D5912 1 E2294 2 J7309 999 L5634 2 S2265 1
A4396 3 D5913 1 E2295 1 J7310 1 L5636 2 S2266 1
A4397 50 D5914 2 E2300 1 J7311 100 L5637 2 S2267 1
A4398 30 D5915 2 E2301 1 J7312 999 L5638 2 S2300 1
A4399 2 D5916 2 E2310 1 J7315 999 L5639 2 S2325 1
A4400 100 D5919 1 E2311 1 J7321 999 L5640 2 S2340 100
A4402 15 D5922 1 E2312 1 J7323 999 L5642 2 S2341 100
A4404 72 D5923 2 E2313 1 J7324 999 L5643 2 S2342 1
A4405 60 D5924 1 E2321 1 J7325 999 L5644 2 S2348 1
A4406 60 D5925 100 E2322 1 J7326 999 L5645 2 S2350 1
A4407 70 D5926 1 E2323 1 J7330 1 L5646 2 S2351 4
A4408 60 D5927 2 E2324 1 J7335 999 L5647 2 S2360 1
A4409 70 D5928 2 E2325 1 J7500 999 L5648 2 S2361 6
A4410 60 D5929 1 E2326 1 J7501 999 L5649 2 S2400 1
A4411 60 D5931 1 E2327 1 J7502 999 L5650 2 S2401 1
A4412 70 D5932 1 E2328 1 J7504 999 L5651 2 S2402 1
A4413 60 D5933 1 E2329 1 J7505 999 L5652 2 S2403 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA4414 75 D5934 1 E2330 1 J7506 999 L5653 2 S2404 1
A4415 60 D5935 1 E2331 1 J7507 999 L5654 2 S2405 1
A4416 75 D5936 1 E2340 1 J7509 999 L5655 2 S2409 999
A4417 60 D5937 1 E2341 1 J7510 999 L5656 2 S2411 100
A4418 60 D5951 100 E2342 1 J7511 999 L5658 2 S2900 1
A4419 75 D5952 1 E2343 1 J7513 999 L5661 2 S3000 1
A4420 100 D5953 1 E2351 1 J7515 999 L5665 2 S3005 1
A4421 999 D5954 1 E2358 2 J7516 999 L5666 2 S3600 3
A4422 100 D5955 1 E2359 2 J7517 999 L5668 2 S3601 1
A4423 60 D5958 1 E2360 100 J7518 999 L5670 2 S3620 7
A4424 60 D5959 1 E2361 2 J7520 999 L5671 2 S3625 100
A4425 70 D5960 1 E2362 100 J7525 999 L5672 2 S3626 100
A4426 70 D5982 2 E2363 2 J7527 999 L5673 2 S3630 100
A4427 60 D5983 1 E2364 100 J7599 999 L5676 2 S3645 100
A4428 70 D5984 1 E2365 2 J7604 999 L5677 2 S3650 100
A4429 100 D5985 1 E2366 1 J7605 999 L5678 2 S3652 100
A4430 75 D5986 2 E2367 1 J7606 999 L5679 2 S3655 100
A4431 100 D5987 1 E2368 2 J7607 999 L5680 2 S3708 100
A4432 70 D5988 1 E2369 2 J7608 999 L5681 2 S3721 100
A4433 60 D5991 1 E2370 2 J7609 999 L5682 2 S3722 100
A4434 60 D5992 1 E2371 2 J7610 999 L5683 2 S3800 100
A4435 100 D5993 1 E2372 100 J7611 999 L5684 2 S3833 2
A4450 73 D5999 999 E2373 1 J7612 999 L5685 12 S3834 100
A4452 75 D6010 32 E2374 1 J7613 999 L5686 2 S3840 100
A4455 60 D6012 32 E2375 1 J7614 999 L5688 2 S3841 100
A4456 75 D6040 32 E2376 1 J7615 999 L5690 2 S3842 100
A4458 30 D6050 16 E2377 1 J7620 999 L5692 2 S3844 100
A4461 4 D6051 32 E2378 2 J7622 999 L5694 2 S3845 100
A4463 3 D6053 2 E2381 2 J7624 999 L5695 2 S3846 100
A4465 3 D6054 2 E2382 2 J7626 999 L5696 2 S3849 100
A4466 4 D6055 2 E2383 2 J7627 999 L5697 2 S3850 100
A4470 1 D6056 32 E2384 4 J7628 999 L5698 2 S3852 100
A4480 1 D6057 32 E2385 4 J7629 999 L5699 2 S3853 100
A4481 75 D6058 32 E2386 2 J7631 999 L5700 2 S3854 1
A4483 75 D6059 32 E2387 4 J7632 999 L5701 2 S3855 100
A4490 12 D6060 32 E2388 2 J7633 999 L5702 2 S3861 100
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA4495 12 D6061 32 E2389 4 J7634 999 L5703 2 S3865 100
A4500 18 D6062 32 E2390 2 J7635 999 L5704 2 S3866 100
A4510 12 D6063 32 E2391 4 J7636 999 L5705 2 S3870 100
A4520 75 D6064 32 E2392 4 J7637 999 L5706 2 S3890 100
A4550 2 D6065 32 E2394 2 J7638 999 L5707 2 S3900 7
A4554 75 D6066 32 E2395 4 J7639 999 L5710 2 S3902 100
A4556 75 D6067 32 E2396 4 J7640 999 L5711 2 S3904 100
A4557 2 D6068 2 E2397 1 J7641 999 L5712 2 S4005 1
A4558 3 D6069 2 E2402 1 J7642 999 L5714 2 S4011 2
A4559 20 D6070 2 E2500 1 J7643 999 L5716 2 S4013 1
A4561 1 D6071 2 E2502 1 J7644 999 L5718 2 S4014 1
A4562 1 D6072 2 E2504 1 J7645 999 L5722 2 S4015 1
A4565 1 D6073 2 E2506 1 J7647 999 L5724 2 S4016 1
A4566 4 D6074 2 E2508 1 J7648 999 L5726 2 S4017 1
A4570 2 D6075 2 E2510 1 J7649 999 L5728 2 S4018 1
A4575 4 D6076 2 E2511 1 J7650 999 L5780 2 S4020 1
A4580 4 D6077 2 E2512 1 J7657 999 L5781 2 S4021 1
A4590 5 D6078 2 E2599 999 J7658 999 L5782 2 S4022 1
A4595 1 D6079 2 E2601 1 J7659 999 L5785 2 S4023 1
A4600 4 D6080 1 E2602 1 J7660 999 L5790 2 S4025 1
A4601 100 D6090 1 E2603 1 J7665 999 L5795 2 S4026 14
A4604 1 D6091 32 E2604 1 J7667 999 L5810 2 S4027 100
A4605 60 D6092 32 E2605 1 J7668 999 L5811 2 S4028 100
A4606 10 D6093 2 E2606 1 J7669 999 L5812 2 S4030 1
A4608 100 D6094 32 E2607 1 J7670 999 L5814 2 S4031 1
A4611 2 D6095 32 E2608 1 J7674 999 L5816 2 S4035 1
A4612 2 D6100 32 E2609 1 J7676 999 L5818 2 S4037 1
A4613 1 D6101 32 E2610 100 J7680 999 L5822 2 S4040 1
A4614 1 D6102 32 E2611 1 J7681 999 L5824 2 S4042 1
A4615 9 D6103 32 E2612 1 J7682 999 L5826 2 S4981 1
A4616 75 D6104 32 E2613 1 J7683 999 L5828 2 S4989 1
A4617 2 D6190 1 E2614 1 J7684 999 L5830 2 S4990 100
A4618 40 D6194 32 E2615 1 J7685 999 L5840 2 S4991 100
A4619 6 D6199 999 E2616 1 J7686 999 L5845 2 S4993 13
A4620 2 D6205 32 E2617 1 J7699 999 L5848 2 S4995 100
A4623 73 D6210 32 E2619 2 J7799 999 L5850 2 S5000 999
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA4624 75 D6211 32 E2620 1 J8498 999 L5855 2 S5001 999
A4625 60 D6212 32 E2621 1 J8499 999 L5856 2 S5010 2
A4626 100 D6214 32 E2622 1 J8501 999 L5857 2 S5011 12
A4627 2 D6240 32 E2623 1 J8510 999 L5858 2 S5012 3
A4628 72 D6241 32 E2624 1 J8515 999 L5859 2 S5013 100
A4629 75 D6242 32 E2625 1 J8520 999 L5910 2 S5014 100
A4630 9 D6245 32 E2626 2 J8521 999 L5920 2 S5035 100
A4633 100 D6250 32 E2627 2 J8530 999 L5925 2 S5036 100
A4634 100 D6251 32 E2628 2 J8540 999 L5930 2 S5100 96
A4635 2 D6252 32 E2629 2 J8560 999 L5940 2 S5101 1
A4636 2 D6253 32 E2630 2 J8562 999 L5950 2 S5102 1
A4637 12 D6545 2 E2631 2 J8565 999 L5960 2 S5105 1
A4638 2 D6548 2 E2632 2 J8597 999 L5961 1 S5108 96
A4639 100 D6600 32 E2633 2 J8600 999 L5962 2 S5109 1
A4640 1 D6601 32 E8000 5 J8610 999 L5964 2 S5110 96
A4641 999 D6602 32 E8001 2 J8650 999 L5966 2 S5111 100
A4642 1 D6603 32 E8002 100 J8700 999 L5968 2 S5115 96
A4648 10 D6604 32 G0008 1 J8705 999 L5970 2 S5116 100
A4649 999 D6605 32 G0009 1 J8999 999 L5971 2 S5120 96
A4650 3 D6606 32 G0010 2 J9000 999 L5972 2 S5121 1
A4651 1 D6607 32 G0027 1 J9002 999 L5973 2 S5125 96
A4652 20 D6608 32 G0101 1 J9010 999 L5974 2 S5126 1
A4653 3 D6609 32 G0102 1 J9015 999 L5975 2 S5130 999
A4657 75 D6610 32 G0103 1 J9017 999 L5976 2 S5131 999
A4660 1 D6611 32 G0104 1 J9019 999 L5978 2 S5135 96
A4663 1 D6612 32 G0105 1 J9020 999 L5979 2 S5136 1
A4670 1 D6613 32 G0106 1 J9025 999 L5980 2 S5140 1
A4671 60 D6614 32 G0108 48 J9027 999 L5981 2 S5141 1
A4672 60 D6615 32 G0109 48 J9031 999 L5982 2 S5145 1
A4673 60 D6624 32 G0117 1 J9033 999 L5984 2 S5146 1
A4674 32 D6634 32 G0118 1 J9035 999 L5985 2 S5150 96
A4680 100 D6710 32 G0120 1 J9040 999 L5986 2 S5151 1
A4690 24 D6720 32 G0121 1 J9041 999 L5987 2 S5160 1
A4706 66 D6721 32 G0122 100 J9042 999 L5988 2 S5161 1
A4707 28 D6722 32 G0123 1 J9043 999 L5990 2 S5162 100
A4708 100 D6740 32 G0124 1 J9045 999 L5999 999 S5165 100
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA4709 65 D6750 32 G0127 1 J9050 999 L6000 2 S5170 63
A4714 100 D6751 32 G0128 1 J9055 999 L6010 2 S5175 100
A4719 71 D6752 32 G0129 1 J9060 999 L6020 2 S5180 1
A4720 100 D6780 32 G0130 1 J9065 999 L6025 2 S5181 999
A4721 100 D6781 32 G0141 1 J9070 999 L6050 2 S5185 1
A4722 75 D6782 32 G0143 1 J9098 999 L6055 2 S5190 1
A4723 100 D6783 32 G0144 1 J9100 999 L6100 2 S5199 999
A4724 100 D6790 32 G0145 1 J9120 999 L6110 2 S5497 999
A4725 74 D6791 32 G0147 1 J9130 999 L6120 2 S5498 1
A4726 74 D6792 32 G0148 1 J9150 999 L6130 2 S5501 1
A4728 100 D6793 32 G0151 96 J9151 999 L6200 2 S5502 1
A4730 50 D6794 32 G0152 96 J9155 999 L6205 2 S5517 15
A4736 4 D6920 2 G0153 96 J9160 999 L6250 2 S5518 100
A4737 75 D6930 100 G0154 96 J9165 999 L6300 2 S5520 100
A4740 100 D6940 2 G0155 96 J9171 999 L6310 2 S5521 30
A4750 16 D6950 4 G0156 96 J9175 999 L6320 2 S5522 100
A4755 30 D6975 4 G0157 96 J9178 999 L6350 2 S5523 1
A4760 2 D6980 100 G0158 96 J9179 999 L6360 2 S5550 999
A4765 60 D6985 2 G0159 96 J9181 999 L6370 2 S5551 999
A4766 100 D6999 999 G0160 96 J9185 999 L6380 2 S5552 999
A4770 1 D7111 20 G0161 96 J9190 999 L6382 2 S5553 999
A4771 100 D7140 32 G0162 96 J9200 999 L6384 2 S5560 100
A4772 2 D7210 32 G0163 96 J9201 999 L6386 2 S5561 100
A4773 2 D7220 32 G0164 96 J9202 3 L6388 2 S5565 100
A4774 100 D7230 32 G0166 2 J9206 999 L6400 2 S5566 100
A4802 100 D7240 32 G0168 2 J9207 999 L6450 2 S5570 100
A4860 60 D7241 32 G0173 1 J9208 999 L6500 2 S5571 100
A4870 100 D7250 32 G0175 1 J9209 999 L6550 2 S8030 100
A4890 4 D7251 32 G0176 16 J9211 999 L6570 2 S8035 100
A4911 66 D7260 1 G0177 55 J9212 999 L6580 2 S8037 2
A4913 999 D7261 1 G0179 1 J9213 999 L6582 2 S8040 100
A4918 100 D7270 32 G0180 1 J9214 999 L6584 2 S8042 100
A4927 6 D7272 32 G0181 1 J9215 999 L6586 2 S8055 100
A4928 50 D7280 32 G0182 1 J9216 999 L6588 2 S8080 1
A4929 100 D7282 32 G0186 1 J9217 999 L6590 2 S8085 1
A4930 6 D7283 32 G0202 1 J9218 999 L6600 2 S8092 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA4931 2 D7285 3 G0204 1 J9219 1 L6605 2 S8096 2
A4932 100 D7286 2 G0206 1 J9225 1 L6610 2 S8097 1
A5051 60 D7287 2 G0219 1 J9226 1 L6611 2 S8100 2
A5052 100 D7288 2 G0235 999 J9228 999 L6615 2 S8101 2
A5053 100 D7290 32 G0237 4 J9230 999 L6616 2 S8110 2
A5054 75 D7291 32 G0238 4 J9245 999 L6620 2 S8120 75
A5055 75 D7292 32 G0239 1 J9250 999 L6621 2 S8121 75
A5056 100 D7293 32 G0245 1 J9260 999 L6623 2 S8130 100
A5057 100 D7294 32 G0246 1 J9261 999 L6624 2 S8131 100
A5061 70 D7295 1 G0247 1 J9263 999 L6625 2 S8185 100
A5062 60 D7310 4 G0248 1 J9264 999 L6628 2 S8186 20
A5063 75 D7311 4 G0249 1 J9265 999 L6629 2 S8189 999
A5071 60 D7320 4 G0250 1 J9266 999 L6630 2 S8210 100
A5072 100 D7321 4 G0251 1 J9268 999 L6632 100 S8262 6
A5073 60 D7340 32 G0252 1 J9270 999 L6635 2 S8265 100
A5081 100 D7350 32 G0255 4 J9280 999 L6637 2 S8270 1
A5082 53 D7410 4 G0257 28 J9293 999 L6638 2 S8301 999
A5083 100 D7411 2 G0259 1 J9300 999 L6640 2 S8415 1
A5093 60 D7412 100 G0260 1 J9302 999 L6641 2 S8420 2
A5102 1 D7413 100 G0268 1 J9303 999 L6642 2 S8421 2
A5105 4 D7414 100 G0269 1 J9305 999 L6645 2 S8422 2
A5112 5 D7415 100 G0270 96 J9307 999 L6646 2 S8423 2
A5113 35 D7440 100 G0271 48 J9310 999 L6647 2 S8424 2
A5114 20 D7441 100 G0275 1 J9315 999 L6648 2 S8425 2
A5120 75 D7450 8 G0278 1 J9320 999 L6650 2 S8426 2
A5121 50 D7451 2 G0281 1 J9328 999 L6655 100 S8427 2
A5122 30 D7460 100 G0282 2 J9330 999 L6660 5 S8428 2
A5126 70 D7461 100 G0283 1 J9340 999 L6665 100 S8429 4
A5131 48 D7465 1 G0288 1 J9351 999 L6670 2 S8430 12
A5200 25 D7471 2 G0289 1 J9355 999 L6672 2 S8431 10
A5500 2 D7472 1 G0293 1 J9357 999 L6675 2 S8450 2
A5501 2 D7473 1 G0294 1 J9360 999 L6676 2 S8451 4
A5503 2 D7485 1 G0295 1 J9370 999 L6677 2 S8452 2
A5504 2 D7490 2 G0302 1 J9390 999 L6680 6 S8460 100
A5505 2 D7510 2 G0303 1 J9395 999 L6682 100 S8490 45
A5506 2 D7511 100 G0304 1 J9600 999 L6684 100 S8930 96
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA5507 2 D7520 100 G0305 1 J9999 999 L6686 2 S8940 4
A5508 2 D7521 100 G0306 2 K0001 1 L6687 2 S8948 4
A5510 2 D7530 1 G0307 2 K0002 1 L6688 2 S8950 96
A5512 6 D7540 1 G0328 1 K0003 1 L6689 2 S8990 2
A5513 6 D7550 1 G0329 1 K0004 1 L6690 2 S8999 2
A6000 1 D7560 2 G0333 1 K0005 1 L6691 100 S9001 1
A6010 999 D7610 1 G0337 1 K0006 1 L6692 100 S9007 100
A6011 999 D7620 1 G0339 1 K0007 1 L6693 2 S9015 1
A6021 75 D7630 1 G0340 1 K0009 1 L6694 2 S9024 100
A6022 60 D7640 1 G0341 1 K0010 1 L6695 2 S9025 100
A6023 100 D7650 1 G0342 1 K0011 1 L6696 2 S9034 1
A6024 100 D7660 1 G0343 1 K0012 1 L6697 2 S9055 100
A6025 12 D7670 32 G0364 2 K0014 1 L6698 2 S9056 1
A6154 20 D7671 32 G0365 2 K0015 2 L6703 2 S9061 1
A6196 70 D7680 1 G0372 1 K0017 2 L6704 2 S9083 1
A6197 75 D7710 1 G0378 24 K0018 2 L6706 2 S9088 2
A6198 100 D7720 1 G0379 1 K0019 2 L6707 2 S9090 2
A6199 66 D7730 1 G0389 1 K0020 1 L6708 2 S9097 1
A6203 75 D7740 1 G0390 1 K0037 2 L6709 2 S9098 1
A6204 60 D7750 1 G0396 1 K0038 2 L6711 2 S9110 1
A6205 50 D7760 1 G0397 1 K0039 2 L6712 2 S9117 1
A6206 12 D7770 32 G0398 1 K0040 2 L6713 2 S9122 24
A6207 74 D7771 32 G0399 1 K0041 2 L6714 2 S9123 24
A6208 7 D7780 1 G0400 1 K0042 2 L6715 1 S9124 24
A6209 75 D7810 2 G0402 1 K0043 2 L6721 2 S9125 1
A6210 72 D7820 2 G0403 1 K0044 2 L6722 2 S9126 1
A6211 74 D7830 2 G0404 1 K0045 2 L6805 2 S9127 1
A6212 75 D7840 1 G0405 1 K0046 2 L6810 2 S9128 1
A6213 40 D7850 2 G0406 1 K0047 2 L6880 2 S9129 1
A6214 100 D7852 2 G0407 1 K0050 2 L6881 2 S9131 1
A6215 50 D7854 2 G0408 1 K0051 2 L6882 2 S9140 1
A6216 75 D7856 100 G0409 96 K0052 2 L6883 2 S9141 1
A6217 70 D7858 2 G0410 1 K0053 2 L6884 2 S9145 1
A6218 10 D7860 2 G0411 1 K0056 1 L6885 2 S9150 1
A6219 75 D7865 2 G0412 1 K0065 2 L6890 2 S9152 5
A6220 62 D7870 2 G0413 1 K0069 2 L6895 2 S9208 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA6221 30 D7871 2 G0414 1 K0070 2 L6900 2 S9209 1
A6222 75 D7872 2 G0415 1 K0071 2 L6905 2 S9211 1
A6223 75 D7873 2 G0416 1 K0072 2 L6910 2 S9212 1
A6224 72 D7874 2 G0417 1 K0073 2 L6915 2 S9213 1
A6228 6 D7875 2 G0418 1 K0077 2 L6920 2 S9214 1
A6229 5 D7876 2 G0419 1 K0098 1 L6925 2 S9325 1
A6230 100 D7877 2 G0420 24 K0105 1 L6930 2 S9326 1
A6231 62 D7880 2 G0421 24 K0108 999 L6935 2 S9327 1
A6232 100 D7899 999 G0422 6 K0195 2 L6940 2 S9328 1
A6233 100 D7910 2 G0423 6 K0455 1 L6945 2 S9329 1
A6234 72 D7911 1 G0424 2 K0462 999 L6950 2 S9330 1
A6235 75 D7912 1 G0425 1 K0552 75 L6955 2 S9331 1
A6236 36 D7920 100 G0426 1 K0601 18 L6960 2 S9335 1
A6237 50 D7921 1 G0427 1 K0602 100 L6965 2 S9336 1
A6238 31 D7940 1 G0428 4 K0603 24 L6970 2 S9338 1
A6239 100 D7941 2 G0429 1 K0604 100 L6975 2 S9339 1
A6240 54 D7943 2 G0431 1 K0605 100 L7007 2 S9340 1
A6241 100 D7944 1 G0432 1 K0606 1 L7008 2 S9341 1
A6242 60 D7945 1 G0433 1 K0607 1 L7009 2 S9342 1
A6243 43 D7946 1 G0434 1 K0608 1 L7040 2 S9343 1
A6244 100 D7947 1 G0435 1 K0609 1 L7045 2 S9345 1
A6245 40 D7948 1 G0436 1 K0669 2 L7170 2 S9346 1
A6246 30 D7949 1 G0437 1 K0672 100 L7180 2 S9347 1
A6247 100 D7950 12 G0438 1 K0730 1 L7181 2 S9348 1
A6248 12 D7951 2 G0439 1 K0733 2 L7185 2 S9349 1
A6250 999 D7952 2 G0442 1 K0738 1 L7186 2 S9351 1
A6251 72 D7953 12 G0443 1 K0739 96 L7190 2 S9353 1
A6252 75 D7955 1 G0444 1 K0740 96 L7191 2 S9355 1
A6253 75 D7960 1 G0445 1 K0743 1 L7260 2 S9357 1
A6254 60 D7963 1 G0446 1 K0744 100 L7261 2 S9359 1
A6255 5 D7970 2 G0447 1 K0745 100 L7360 100 S9361 1
A6256 100 D7971 32 G0448 1 K0746 100 L7362 1 S9363 1
A6257 72 D7972 1 G0451 100 K0800 1 L7364 3 S9364 1
A6258 69 D7980 100 G0452 100 K0801 1 L7366 1 S9365 1
A6259 50 D7981 100 G0453 96 K0802 1 L7367 3 S9366 1
A6260 4 D7982 100 G0454 1 K0806 1 L7368 1 S9367 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA6261 40 D7983 100 G0455 1 K0807 1 L7400 2 S9368 1
A6262 24 D7990 1 G0456 1 K0808 1 L7401 2 S9370 1
A6266 75 D7991 2 G0457 1 K0812 999 L7402 2 S9372 1
A6402 75 D7995 1 G0458 100 K0813 1 L7403 2 S9373 1
A6403 75 D7996 1 G3001 100 K0814 1 L7404 2 S9374 1
A6404 6 D7997 2 G9001 1 K0815 1 L7405 2 S9375 1
A6407 75 D7998 1 G9002 1 K0816 1 L7499 999 S9376 1
A6410 2 D7999 999 G9003 1 K0820 1 L7510 7 S9377 1
A6411 1 D8010 1 G9004 1 K0821 1 L7520 96 S9379 999
A6412 50 D8020 1 G9005 1 K0822 1 L7600 100 S9381 100
A6413 12 D8030 1 G9006 1 K0823 1 L7900 1 S9401 1
A6441 64 D8040 1 G9007 1 K0824 1 L7902 1 S9430 5
A6442 49 D8050 1 G9008 1 K0825 1 L8000 6 S9433 100
A6443 75 D8060 1 G9009 1 K0826 1 L8001 6 S9434 100
A6444 54 D8070 1 G9010 1 K0827 1 L8002 6 S9435 26
A6445 72 D8080 1 G9011 1 K0828 1 L8010 7 S9436 1
A6446 75 D8090 1 G9012 1 K0829 1 L8015 2 S9437 1
A6447 75 D8210 1 G9143 1 K0830 1 L8020 2 S9438 1
A6448 5 D8220 1 G9147 100 K0831 1 L8030 2 S9439 1
A6449 75 D8660 1 G9156 1 K0835 1 L8031 2 S9441 1
A6450 5 D8670 1 G9157 100 K0836 1 L8032 2 S9442 1
A6451 4 D8680 1 H0001 2 K0837 1 L8035 2 S9443 1
A6452 75 D8690 1 H0002 40 K0838 1 L8039 999 S9444 1
A6453 10 D8691 2 H0003 8 K0839 1 L8040 1 S9445 999
A6454 75 D8692 2 H0004 96 K0840 1 L8041 1 S9446 999
A6455 2 D8693 1 H0005 30 K0841 1 L8042 2 S9447 1
A6456 70 D8999 999 H0006 16 K0842 1 L8043 1 S9449 1
A6457 60 D9110 1 H0007 100 K0843 1 L8044 1 S9451 1
A6501 2 D9120 2 H0008 100 K0848 1 L8045 2 S9452 1
A6502 2 D9310 1 H0009 100 K0849 1 L8046 1 S9453 1
A6503 2 D9410 1 H0010 2 K0850 1 L8047 1 S9454 1
A6504 4 D9420 1 H0011 4 K0851 1 L8048 999 S9455 20
A6505 4 D9430 1 H0012 100 K0852 1 L8049 96 S9460 8
A6506 4 D9440 1 H0013 100 K0853 1 L8300 1 S9465 8
A6507 4 D9450 1 H0014 7 K0854 1 L8310 1 S9470 6
A6508 4 D9610 1 H0015 5 K0855 1 L8320 2 S9472 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA6509 2 D9612 1 H0016 4 K0856 1 L8330 2 S9473 1
A6510 2 D9630 4 H0017 1 K0857 1 L8400 24 S9474 1
A6511 2 D9910 1 H0018 1 K0858 1 L8410 12 S9475 1
A6512 999 D9911 32 H0019 1 K0859 1 L8415 100 S9476 1
A6513 2 D9920 1 H0020 65 K0860 1 L8417 24 S9480 1
A6530 10 D9930 1 H0021 100 K0861 1 L8420 36 S9482 96
A6531 24 D9940 2 H0022 15 K0862 1 L8430 25 S9484 24
A6532 16 D9941 1 H0023 2 K0863 1 L8435 18 S9485 1
A6533 30 D9942 2 H0024 24 K0864 1 L8440 16 S9490 1
A6534 4 D9950 2 H0025 24 K0868 1 L8460 10 S9494 1
A6535 16 D9951 2 H0026 100 K0869 1 L8465 100 S9497 1
A6536 14 D9952 1 H0027 100 K0870 1 L8470 40 S9500 1
A6537 12 D9970 32 H0028 100 K0871 1 L8480 25 S9501 1
A6538 100 D9971 16 H0029 100 K0877 1 L8485 12 S9502 1
A6539 16 D9972 2 H0030 100 K0878 1 L8499 999 S9503 1
A6540 15 D9973 32 H0031 60 K0879 1 L8500 1 S9504 1
A6541 8 D9974 32 H0032 60 K0880 1 L8501 2 S9529 1
A6544 2 D9975 2 H0033 2 K0884 1 L8505 100 S9537 1
A6545 2 D9999 999 H0034 96 K0885 1 L8507 3 S9538 1
A6549 999 E0100 1 H0035 1 K0886 1 L8509 1 S9542 999
A6550 65 E0105 1 H0036 96 K0890 1 L8510 1 S9558 1
A7000 15 E0110 1 H0037 1 K0891 1 L8511 1 S9559 1
A7001 30 E0111 2 H0038 96 K0898 999 L8512 100 S9560 1
A7002 8 E0112 1 H0039 96 K0899 1 L8513 100 S9562 1
A7003 5 E0113 2 H0040 1 L0112 1 L8514 1 S9590 1
A7004 6 E0114 1 H0041 1 L0113 1 L8515 1 S9810 999
A7005 1 E0116 2 H0042 1 L0120 1 L8600 2 S9900 1
A7006 4 E0117 2 H0043 1 L0130 1 L8603 6 S9970 1
A7007 6 E0118 1 H0044 1 L0140 1 L8604 3 S9975 1
A7008 30 E0130 1 H0045 1 L0150 1 L8605 1 S9976 999
A7009 6 E0135 1 H0046 999 L0160 1 L8606 10 S9977 999
A7010 2 E0140 1 H0047 999 L0170 1 L8609 1 S9981 1
A7011 7 E0141 1 H0048 2 L0172 1 L8610 2 S9982 56
A7012 8 E0143 1 H0049 100 L0174 1 L8612 2 S9986 8
A7013 6 E0144 1 H0050 96 L0180 1 L8613 2 S9988 100
A7014 1 E0147 1 H1000 4 L0190 1 L8614 2 S9989 100
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA7015 2 E0148 1 H1001 2 L0200 1 L8615 2 S9990 100
A7016 1 E0149 1 H1002 5 L0220 1 L8616 2 S9991 100
A7017 1 E0153 2 H1003 6 L0430 1 L8617 2 S9992 100
A7018 24 E0154 2 H1004 1 L0450 1 L8618 2 S9994 100
A7020 1 E0155 1 H1005 1 L0452 1 L8619 2 S9996 100
A7025 1 E0156 1 H1010 1 L0454 1 L8621 60 S9999 2
A7026 1 E0157 2 H1011 100 L0456 1 L8622 2 T1000 96
A7027 1 E0158 1 H2000 24 L0458 1 L8623 4 T1001 4
A7028 8 E0159 2 H2001 2 L0460 1 L8624 10 T1002 96
A7029 6 E0160 1 H2010 96 L0462 1 L8627 2 T1003 96
A7030 1 E0161 1 H2011 96 L0464 1 L8628 2 T1004 96
A7031 3 E0162 1 H2012 24 L0466 1 L8629 2 T1005 96
A7032 5 E0163 1 H2013 1 L0468 1 L8630 5 T1006 10
A7033 6 E0165 1 H2014 96 L0470 1 L8631 5 T1007 7
A7034 1 E0167 1 H2015 96 L0472 1 L8641 5 T1009 100
A7035 1 E0168 1 H2016 1 L0480 1 L8642 2 T1010 100
A7036 1 E0170 1 H2017 96 L0482 1 L8658 9 T1012 100
A7037 2 E0171 1 H2018 1 L0484 1 L8659 9 T1013 96
A7038 6 E0172 1 H2019 96 L0486 1 L8670 4 T1014 999
A7039 1 E0175 2 H2020 1 L0488 1 L8680 46 T1015 55
A7040 2 E0181 1 H2021 96 L0490 1 L8681 1 T1016 96
A7041 2 E0182 1 H2022 1 L0491 1 L8682 2 T1017 96
A7042 2 E0184 1 H2023 96 L0492 1 L8683 1 T1018 100
A7043 2 E0185 1 H2024 1 L0621 1 L8684 1 T1019 96
A7044 1 E0186 1 H2025 96 L0622 1 L8685 1 T1020 1
A7045 1 E0187 1 H2026 1 L0623 1 L8686 2 T1021 52
A7046 1 E0188 1 H2027 96 L0624 1 L8687 1 T1022 1
A7501 100 E0189 1 H2028 96 L0625 1 L8688 1 T1023 8
A7502 1 E0190 2 H2029 1 L0626 1 L8689 1 T1024 64
A7503 3 E0191 4 H2030 96 L0627 1 L8690 2 T1025 1
A7504 75 E0193 1 H2031 1 L0628 1 L8691 2 T1026 24
A7505 67 E0194 1 H2032 96 L0629 1 L8692 1 T1027 96
A7506 60 E0196 1 H2033 96 L0630 1 L8693 1 T1028 36
A7507 75 E0197 1 H2034 1 L0631 1 L8695 1 T1029 100
A7508 75 E0198 1 H2035 24 L0632 1 L8699 999 T1030 1
A7509 66 E0199 1 H2036 1 L0633 1 L9900 999 T1031 1
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA7520 5 E0200 1 H2037 96 L0634 1 M0064 1 T1502 10
A7521 4 E0202 1 J0120 999 L0635 1 M0075 100 T1503 100
A7522 1 E0203 1 J0129 999 L0636 1 M0076 7 T1505 1
A7523 30 E0205 1 J0130 999 L0637 1 M0100 100 T1999 999
A7524 2 E0210 1 J0131 999 L0638 1 M0300 2 T2001 7
A7525 50 E0215 1 J0132 999 L0639 1 M0301 100 T2002 1
A7526 75 E0217 1 J0133 999 L0640 1 P2028 1 T2003 40
A7527 10 E0218 1 J0135 999 L0700 1 P2029 1 T2004 100
A8000 100 E0221 1 J0150 999 L0710 1 P2031 100 T2005 2
A8001 100 E0225 1 J0152 999 L0810 1 P2033 1 T2007 48
A8002 100 E0231 100 J0171 999 L0820 1 P2038 1 T2010 100
A8003 1 E0232 100 J0178 999 L0830 1 P3000 1 T2011 100
A8004 100 E0235 1 J0180 999 L0859 1 P3001 1 T2012 1
A9150 999 E0236 1 J0190 999 L0861 1 P7001 2 T2013 24
A9152 12 E0239 1 J0200 999 L0970 1 P9010 100 T2014 1
A9153 13 E0240 1 J0205 999 L0972 1 P9011 100 T2015 24
A9155 100 E0241 2 J0207 999 L0974 1 P9012 100 T2016 1
A9180 6 E0242 2 J0210 999 L0976 1 P9016 6 T2017 96
A9270 999 E0243 2 J0215 999 L0978 2 P9017 14 T2018 1
A9272 100 E0244 1 J0220 999 L0980 1 P9019 2 T2019 96
A9273 4 E0245 1 J0221 999 L0982 100 P9020 2 T2020 1
A9274 70 E0246 100 J0256 999 L0984 14 P9021 20 T2021 96
A9275 2 E0247 1 J0257 999 L0999 999 P9022 100 T2022 1
A9276 90 E0248 1 J0270 999 L1000 1 P9023 100 T2023 1
A9277 1 E0249 1 J0275 999 L1001 1 P9031 100 T2024 100
A9278 1 E0250 1 J0278 999 L1005 1 P9032 100 T2025 999
A9279 999 E0251 1 J0280 999 L1010 2 P9033 100 T2026 1
A9280 999 E0255 1 J0282 999 L1020 2 P9034 100 T2027 96
A9281 100 E0256 1 J0285 999 L1025 1 P9035 3 T2028 4
A9282 10 E0260 1 J0287 999 L1030 1 P9036 100 T2029 1
A9283 4 E0261 1 J0288 999 L1040 1 P9037 2 T2030 1
A9284 1 E0265 1 J0289 999 L1050 1 P9038 100 T2031 1
A9300 999 E0266 1 J0290 999 L1060 1 P9039 100 T2032 1
A9500 3 E0270 1 J0295 999 L1070 2 P9040 4 T2033 1
A9501 3 E0271 1 J0300 999 L1080 2 P9041 60 T2034 1
A9502 3 E0272 1 J0330 999 L1085 1 P9043 100 T2035 100
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA9503 1 E0273 1 J0348 999 L1090 1 P9044 100 T2036 1
A9504 1 E0274 1 J0350 999 L1100 2 P9045 30 T2037 100
A9505 999 E0275 1 J0360 999 L1110 2 P9046 100 T2038 100
A9507 1 E0276 1 J0364 999 L1120 3 P9047 25 T2039 100
A9508 999 E0277 1 J0365 999 L1200 1 P9048 100 T2040 96
A9509 999 E0280 1 J0380 999 L1210 2 P9050 100 T2041 96
A9510 1 E0290 1 J0390 999 L1220 1 P9051 100 T2042 1
A9512 999 E0291 1 J0395 999 L1230 1 P9052 100 T2043 24
A9516 999 E0292 1 J0400 999 L1240 1 P9053 2 T2044 1
A9517 999 E0293 1 J0456 999 L1250 2 P9054 100 T2045 1
A9521 2 E0294 1 J0461 999 L1260 1 P9055 100 T2046 1
A9524 999 E0295 1 J0470 999 L1270 3 P9056 100 T2048 1
A9526 2 E0296 1 J0475 999 L1280 2 P9057 100 T2049 66
A9527 999 E0297 1 J0476 999 L1290 2 P9058 4 T2101 100
A9528 999 E0300 1 J0480 999 L1300 1 P9059 100 T4521 75
A9529 999 E0301 1 J0485 999 L1310 1 P9060 100 T4522 75
A9530 999 E0302 1 J0490 999 L1499 999 P9603 75 T4523 72
A9531 999 E0303 1 J0500 999 L1600 1 P9604 2 T4524 72
A9532 999 E0304 1 J0515 999 L1610 1 P9612 1 T4525 72
A9536 1 E0305 1 J0520 999 L1620 1 P9615 1 T4526 72
A9537 1 E0310 2 J0558 999 L1630 1 Q0035 1 T4527 72
A9538 1 E0315 100 J0561 999 L1640 1 Q0081 2 T4528 72
A9539 2 E0316 1 J0583 999 L1650 1 Q0083 2 T4529 68
A9540 2 E0325 1 J0585 999 L1652 1 Q0084 1 T4530 72
A9541 1 E0326 1 J0586 999 L1660 1 Q0085 100 T4531 75
A9542 1 E0328 1 J0587 999 L1680 1 Q0091 1 T4532 72
A9543 1 E0329 1 J0588 999 L1685 1 Q0092 5 T4533 75
A9544 1 E0350 1 J0592 999 L1686 1 Q0111 2 T4534 75
A9545 1 E0352 100 J0594 999 L1690 1 Q0112 3 T4535 75
A9546 1 E0370 2 J0595 999 L1700 1 Q0113 2 T4536 100
A9547 999 E0371 1 J0597 999 L1710 1 Q0114 1 T4537 72
A9548 999 E0372 1 J0598 999 L1720 2 Q0115 1 T4538 100
A9550 1 E0373 1 J0600 999 L1730 1 Q0138 999 T4539 5
A9551 1 E0424 1 J0610 999 L1755 2 Q0139 999 T4540 7
A9552 1 E0425 1 J0620 999 L1810 2 Q0144 999 T4541 75
A9553 1 E0430 1 J0630 999 L1820 2 Q0162 999 T4542 100
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA9554 1 E0431 1 J0636 999 L1830 2 Q0163 999 T4543 100
A9555 3 E0433 1 J0637 999 L1831 2 Q0164 999 T5001 100
A9556 999 E0434 1 J0638 999 L1832 2 Q0165 999 T5999 999
A9557 2 E0435 1 J0640 999 L1834 2 Q0166 999 V2020 1
A9558 999 E0439 1 J0641 999 L1836 2 Q0167 999 V2025 1
A9559 1 E0440 1 J0670 999 L1840 2 Q0168 999 V2100 3
A9560 2 E0441 1 J0690 999 L1843 2 Q0169 999 V2101 2
A9561 1 E0442 1 J0692 999 L1844 2 Q0170 999 V2102 2
A9562 2 E0443 1 J0694 999 L1845 2 Q0171 999 V2103 2
A9563 999 E0444 1 J0696 999 L1846 2 Q0172 999 V2104 2
A9564 999 E0445 1 J0697 999 L1847 2 Q0173 999 V2105 2
A9566 1 E0446 1 J0698 999 L1850 2 Q0174 999 V2106 2
A9567 2 E0450 2 J0702 999 L1860 2 Q0175 999 V2107 2
A9568 999 E0455 1 J0706 999 L1900 2 Q0176 999 V2108 2
A9569 1 E0457 1 J0710 999 L1902 2 Q0177 999 V2109 2
A9570 1 E0459 1 J0712 999 L1904 2 Q0178 999 V2110 2
A9571 1 E0460 2 J0713 999 L1906 2 Q0180 999 V2111 2
A9572 999 E0461 2 J0715 999 L1907 2 Q0181 999 V2112 2
A9576 999 E0462 1 J0716 999 L1910 2 Q0478 1 V2113 2
A9577 999 E0463 2 J0718 999 L1920 2 Q0479 1 V2114 2
A9578 999 E0464 2 J0720 999 L1930 2 Q0480 1 V2115 2
A9579 999 E0470 1 J0725 999 L1932 2 Q0481 1 V2118 2
A9580 1 E0471 1 J0735 999 L1940 2 Q0482 1 V2121 2
A9581 999 E0472 1 J0740 999 L1945 2 Q0483 1 V2199 999
A9582 1 E0480 1 J0743 999 L1950 2 Q0484 1 V2200 2
A9583 999 E0481 1 J0744 999 L1951 2 Q0485 1 V2201 2
A9584 1 E0482 1 J0745 999 L1960 2 Q0486 1 V2202 2
A9585 999 E0483 1 J0760 999 L1970 2 Q0487 1 V2203 2
A9586 999 E0484 1 J0770 999 L1971 2 Q0488 1 V2204 2
A9600 999 E0485 1 J0775 999 L1980 2 Q0489 1 V2205 2
A9604 1 E0486 1 J0780 999 L1990 2 Q0490 1 V2206 2
A9698 999 E0487 1 J0795 999 L2000 2 Q0491 1 V2207 2
A9699 999 E0500 1 J0800 999 L2005 2 Q0492 1 V2208 2
A9700 2 E0550 1 J0833 999 L2010 2 Q0493 1 V2209 2
A9900 999 E0555 1 J0834 999 L2020 2 Q0494 1 V2210 2
A9901 1 E0560 1 J0840 999 L2030 2 Q0495 1 V2211 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueA9999 999 E0561 1 J0850 999 L2034 2 Q0496 100 V2212 2
B4034 1 E0562 1 J0878 999 L2035 2 Q0497 2 V2213 2
B4035 1 E0565 1 J0881 999 L2036 2 Q0498 1 V2214 2
B4036 1 E0570 1 J0882 999 L2037 2 Q0499 1 V2215 2
B4081 20 E0572 1 J0885 999 L2038 2 Q0500 100 V2218 2
B4082 50 E0574 1 J0886 999 L2040 1 Q0501 1 V2219 2
B4083 100 E0575 1 J0890 999 L2050 1 Q0502 1 V2220 2
B4087 1 E0580 1 J0894 999 L2060 1 Q0503 3 V2221 2
B4088 1 E0585 1 J0895 999 L2070 1 Q0504 1 V2299 2
B4100 75 E0600 1 J0897 999 L2080 1 Q0505 999 V2300 2
B4102 100 E0601 1 J0900 999 L2090 1 Q0506 100 V2301 2
B4103 32 E0602 1 J0945 999 L2106 2 Q0510 1 V2302 2
B4104 36 E0603 1 J1000 999 L2108 2 Q0511 1 V2303 2
B4149 75 E0604 1 J1020 999 L2112 2 Q0512 3 V2304 2
B4150 75 E0605 1 J1030 999 L2114 2 Q0513 1 V2305 2
B4152 75 E0606 1 J1040 999 L2116 2 Q0514 1 V2306 2
B4153 75 E0607 1 J1050 999 L2126 2 Q0515 999 V2307 2
B4154 75 E0610 1 J1060 999 L2128 2 Q1004 2 V2308 2
B4155 75 E0615 1 J1070 999 L2132 2 Q1005 2 V2309 2
B4157 66 E0616 1 J1080 999 L2134 2 Q2004 100 V2310 2
B4158 75 E0617 1 J1094 999 L2136 2 Q2009 999 V2311 2
B4159 100 E0618 1 J1100 999 L2180 2 Q2017 999 V2312 2
B4160 75 E0619 1 J1110 999 L2182 2 Q2026 999 V2313 2
B4161 75 E0620 1 J1120 999 L2184 2 Q2027 999 V2314 2
B4162 67 E0621 1 J1160 999 L2186 2 Q2034 1 V2315 2
B4164 100 E0625 999 J1162 999 L2188 2 Q2035 1 V2318 2
B4168 3 E0627 1 J1165 999 L2190 2 Q2036 1 V2319 2
B4172 100 E0628 1 J1170 999 L2192 2 Q2037 1 V2320 2
B4176 100 E0629 1 J1180 999 L2200 2 Q2038 1 V2321 2
B4178 24 E0630 1 J1190 999 L2210 12 Q2039 1 V2399 2
B4180 100 E0635 1 J1200 999 L2220 2 Q2043 1 V2410 2
B4185 75 E0636 1 J1205 999 L2230 2 Q2049 999 V2430 2
B4189 67 E0637 1 J1212 999 L2232 2 Q3001 125 V2499 4
B4193 1 E0638 1 J1230 999 L2240 2 Q3014 15 V2500 2
B4197 1 E0639 1 J1240 999 L2250 2 Q3025 999 V2501 2
B4199 62 E0640 1 J1245 999 L2260 2 Q3026 999 V2502 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueB4216 1 E0641 1 J1250 999 L2265 2 Q3031 100 V2503 2
B4220 1 E0642 1 J1260 999 L2270 2 Q4001 1 V2510 2
B4222 1 E0650 1 J1265 999 L2275 2 Q4002 1 V2511 2
B4224 1 E0651 1 J1267 999 L2280 2 Q4003 2 V2512 2
B5000 1 E0652 1 J1270 999 L2300 1 Q4004 2 V2513 2
B5100 1 E0655 2 J1290 999 L2310 1 Q4005 3 V2520 2
B5200 1 E0656 1 J1300 999 L2320 2 Q4006 3 V2521 2
B9000 1 E0657 1 J1320 999 L2330 2 Q4007 2 V2522 2
B9002 1 E0660 2 J1324 999 L2335 2 Q4008 2 V2523 2
B9004 1 E0665 2 J1325 999 L2340 2 Q4009 2 V2530 2
B9006 1 E0666 2 J1327 999 L2350 2 Q4010 2 V2531 2
B9998 999 E0667 2 J1330 999 L2360 2 Q4011 2 V2599 72
B9999 999 E0668 2 J1335 999 L2370 2 Q4012 2 V2600 1
D0120 1 E0669 2 J1364 999 L2375 2 Q4013 2 V2610 1
D0140 1 E0670 2 J1380 999 L2380 2 Q4014 2 V2615 2
D0145 1 E0671 2 J1410 999 L2385 2 Q4015 100 V2623 2
D0150 1 E0672 2 J1430 999 L2387 2 Q4016 1 V2624 2
D0160 1 E0673 2 J1435 999 L2390 2 Q4017 48 V2625 2
D0170 1 E0675 1 J1436 999 L2395 2 Q4018 2 V2626 2
D0180 1 E0676 30 J1438 999 L2397 2 Q4019 21 V2627 2
D0190 1 E0691 1 J1440 999 L2405 2 Q4020 2 V2628 2
D0191 1 E0692 1 J1441 999 L2415 2 Q4021 2 V2629 2
D0210 1 E0693 1 J1450 999 L2425 2 Q4022 1 V2630 2
D0220 1 E0694 1 J1451 999 L2430 2 Q4023 2 V2631 2
D0230 5 E0700 2 J1452 999 L2492 2 Q4024 3 V2632 2
D0240 2 E0705 1 J1453 999 L2500 2 Q4025 1 V2700 2
D0250 1 E0710 100 J1455 999 L2510 2 Q4026 1 V2702 8
D0260 100 E0720 1 J1457 999 L2520 2 Q4027 1 V2710 2
D0270 1 E0730 1 J1458 999 L2525 2 Q4028 1 V2715 20
D0272 1 E0731 1 J1459 999 L2526 2 Q4029 2 V2718 2
D0273 1 E0740 1 J1460 10 L2530 2 Q4030 10 V2730 2
D0274 1 E0744 1 J1557 999 L2540 2 Q4031 6 V2744 2
D0277 1 E0745 1 J1559 999 L2550 2 Q4032 8 V2745 7
D0290 2 E0746 1 J1560 1 L2570 2 Q4033 100 V2750 2
D0310 100 E0747 1 J1561 999 L2580 2 Q4034 3 V2755 6
D0320 2 E0748 1 J1562 999 L2600 2 Q4035 100 V2756 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueD0321 4 E0749 1 J1566 999 L2610 2 Q4036 2 V2760 2
D0322 8 E0755 1 J1568 999 L2620 2 Q4037 10 V2761 2
D0330 1 E0760 1 J1569 999 L2622 2 Q4038 3 V2762 4
D0340 1 E0761 1 J1570 999 L2624 2 Q4039 3 V2770 2
D0350 1 E0762 1 J1571 999 L2627 1 Q4040 6 V2780 2
D0363 1 E0764 1 J1572 999 L2628 1 Q4041 1 V2781 2
D0364 1 E0765 1 J1573 999 L2630 1 Q4042 4 V2782 2
D0365 1 E0769 999 J1580 999 L2640 1 Q4043 100 V2783 2
D0366 1 E0770 1 J1590 999 L2650 2 Q4044 2 V2784 2
D0367 1 E0776 1 J1595 999 L2660 1 Q4045 3 V2785 2
D0368 1 E0779 1 J1599 999 L2670 2 Q4046 2 V2786 100
D0369 1 E0780 1 J1600 999 L2680 2 Q4047 8 V2787 2
D0370 1 E0781 1 J1610 999 L2750 4 Q4048 3 V2788 2
D0371 1 E0782 1 J1620 999 L2755 8 Q4049 5 V2790 1
D0380 1 E0783 1 J1626 999 L2760 18 Q4050 999 V2797 1
D0381 1 E0784 1 J1630 999 L2768 6 Q4051 999 V2799 999
D0382 1 E0785 1 J1631 999 L2780 18 Q4074 999 V5008 1
D0383 1 E0786 1 J1640 999 L2785 2 Q4081 999 V5010 1
D0384 1 E0791 1 J1642 999 L2795 2 Q4082 999 V5011 1
D0385 1 E0830 2 J1644 999 L2800 2 Q4100 999 V5014 2
D0386 1 E0840 1 J1645 999 L2810 2 Q4101 999 V5020 2
D0391 1 E0849 1 J1650 999 L2820 2 Q4102 999 V5030 2
D0415 1 E0850 1 J1652 999 L2830 2 Q4103 999 V5040 2
D0416 1 E0855 1 J1655 999 L2840 24 Q4104 999 V5050 2
D0417 1 E0856 1 J1670 999 L2850 12 Q4105 999 V5060 2
D0418 1 E0860 1 J1675 999 L2861 8 Q4106 999 V5070 100
D0421 1 E0870 1 J1700 999 L2999 999 Q4107 999 V5080 100
D0425 1 E0880 1 J1710 999 L3000 2 Q4108 999 V5090 2
D0431 1 E0890 1 J1720 999 L3001 2 Q4110 999 V5095 100
D0460 1 E0900 1 J1725 999 L3002 2 Q4111 999 V5100 1
D0470 1 E0910 1 J1730 999 L3003 2 Q4112 999 V5110 2
D0472 1 E0911 1 J1740 999 L3010 2 Q4113 999 V5120 1
D0473 2 E0912 1 J1741 999 L3020 2 Q4114 999 V5130 1
D0474 1 E0920 1 J1742 999 L3030 2 Q4115 999 V5140 1
D0475 1 E0930 1 J1743 999 L3031 2 Q4116 999 V5150 1
D0476 1 E0935 1 J1744 999 L3040 2 Q4117 999 V5160 2
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueD0477 1 E0936 1 J1745 999 L3050 2 Q4118 999 V5170 2
D0478 1 E0940 1 J1750 999 L3060 2 Q4119 999 V5180 2
D0479 1 E0941 1 J1756 999 L3070 2 Q4120 999 V5190 2
D0480 1 E0942 1 J1786 999 L3080 2 Q4121 999 V5200 100
D0481 1 E0944 1 J1790 999 L3090 2 Q4122 999 V5210 1
D0482 1 E0945 2 J1800 999 L3100 2 Q4123 999 V5220 1
D0483 1 E0946 1 J1810 999 L3140 1 Q4124 999 V5230 1
D0484 1 E0947 1 J1815 999 L3150 1 Q4125 999 V5240 100
D0485 1 E0948 1 J1817 999 L3160 2 Q4126 999 V5241 2
D0486 1 E0950 1 J1826 999 L3170 2 Q4127 999 V5242 2
D0502 1 E0951 2 J1830 999 L3201 2 Q4128 999 V5243 2
D0999 999 E0952 2 J1835 999 L3202 4 Q4129 999 V5244 2
D1110 1 E0955 1 J1840 999 L3203 4 Q4130 999 V5245 2
D1120 1 E0956 8 J1850 999 L3204 100 Q4131 999 V5246 2
D1206 1 E0957 2 J1885 999 L3206 3 Q4132 999 V5247 2
D1208 1 E0958 2 J1890 999 L3207 100 Q4133 999 V5248 1
D1310 1 E0959 2 J1930 999 L3208 2 Q4134 999 V5249 1
D1320 1 E0960 2 J1931 999 L3209 2 Q4135 999 V5250 1
D1330 1 E0961 2 J1940 999 L3211 2 Q4136 999 V5251 1
D1351 32 E0966 1 J1945 999 L3212 1 Q5001 31 V5252 1
D1352 32 E0967 2 J1950 999 L3213 1 Q5002 31 V5253 1
D1510 2 E0968 1 J1953 999 L3214 1 Q5003 31 V5254 2
D1515 2 E0969 1 J1955 999 L3215 2 Q5004 31 V5255 2
D1520 2 E0970 2 J1956 999 L3216 2 Q5005 100 V5256 2
D1525 2 E0971 2 J1960 999 L3217 2 Q5006 31 V5257 2
D1550 2 E0973 2 J1980 999 L3219 2 Q5007 100 V5258 1
D1555 1 E0974 2 J1990 999 L3221 2 Q5008 100 V5259 1
D2140 32 E0978 1 J2001 999 L3222 2 Q5009 999 V5260 1
D2150 32 E0980 1 J2010 999 L3224 2 Q5010 100 V5261 1
D2160 32 E0981 1 J2020 999 L3225 2 Q9951 999 V5262 2
D2161 32 E0982 1 J2060 999 L3230 2 Q9953 999 V5263 1
D2330 32 E0983 1 J2150 999 L3250 2 Q9954 999 V5264 2
D2331 32 E0984 1 J2170 999 L3251 2 Q9955 999 V5265 4
D2332 32 E0985 1 J2175 999 L3252 2 Q9956 999 V5266 62
D2335 32 E0986 1 J2180 999 L3253 2 Q9957 999 V5267 4
D2390 32 E0988 1 J2185 999 L3254 2 Q9958 999 V5268 100
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List
Code Value Code Value Code Value Code Value Code Value Code ValueD2391 32 E0990 2 J2210 999 L3255 2 Q9959 999 V5269 100
D2392 32 E0992 1 J2212 999 L3257 2 Q9960 999 V5270 100
D2393 32 E0994 2 J2248 999 L3260 2 Q9961 999 V5271 100
D2394 32 E0995 2 J2250 999 L3265 2 Q9962 999 V5272 100
D2410 32 E1002 1 J2260 999 L3300 6 Q9963 999 V5273 100
D2420 32 E1003 1 J2265 999 L3310 9 Q9964 999 V5274 999
D2430 32 E1004 1 J2270 999 L3320 8 Q9965 999 V5275 2
D2510 32 E1005 1 J2271 999 L3330 2 Q9966 999 V5281 2
D2520 32 E1006 1 J2275 999 L3332 2 Q9967 999 V5282 1
D2530 32 E1007 1 J2278 999 L3334 10 Q9968 999 V5283 100
D2542 32 E1008 1 J2280 999 L3340 2 Q9969 999 V5284 100
D2543 32 E1009 2 J2300 999 L3350 2 R0070 2 V5285 100
D2544 32 E1010 1 J2310 999 L3360 2 R0075 2 V5286 100
D2610 32 E1011 1 J2315 999 L3370 2 R0076 1 V5287 100
D2620 32 E1014 1 J2320 999 L3380 2 S0012 999 V5288 100
D2630 32 E1015 2 J2323 999 L3390 2 S0014 999 V5289 100
D2642 32 E1016 2 J2325 999 L3400 2 S0017 999 V5290 100
D2643 32 E1017 2 J2353 999 L3410 2 S0020 999 V5298 999
D2644 32 E1018 2 J2354 999 L3420 2 S0021 999 V5299 999
D2650 32 E1020 2 J2355 999 L3430 2 S0023 999 V5336 2
D2651 32 E1028 4 J2357 999 L3440 2 S0028 999 V5362 1
D2652 32 E1029 1 J2358 999 L3450 2 S0030 999 V5363 1
D2662 32 E1030 1 J2360 999 L3455 2 S0032 999 V5364 1
D2663 32
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2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
0019T 33202 51065 76999 87430 A0190 E0200 J9340
0042T 33203 51080 77001 87449 A0200 E0202 J9351
0051T 33206 51100 77002 87450 A0210 E0203 J9355
0052T 33207 51101 77003 87451 A0225 E0205 J9357
0053T 33208 51102 77011 87470 A0380 E0210 J9360
0054T 33210 51500 77012 87471 A0382 E0215 J9370
0055T 33211 51520 77013 87472 A0384 E0217 J9390
0058T 33212 51525 77014 87475 A0390 E0218 J9395
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
0059T 33213 51530 77021 87476 A0392 E0221 J9600
0071T 33214 51550 77022 87477 A0394 E0225 J9999
0072T 33215 51555 77031 87480 A0396 E0231 K0001
0073T 33216 51565 77032 87481 A0398 E0232 K0002
0075T 33217 51570 77051 87482 A0420 E0235 K0003
0076T 33218 51575 77052 87485 A0422 E0236 K0004
0078T 33220 51580 77053 87486 A0424 E0239 K0005
0079T 33221 51585 77054 87487 A0425 E0240 K0006
0080T 33222 51590 77055 87490 A0426 E0241 K0007
0081T 33223 51595 77056 87491 A0427 E0242 K0009
0085T 33224 51596 77057 87492 A0428 E0243 K0010
0092T 33225 51597 77058 87493 A0429 E0244 K0011
0095T 33226 51600 77059 87495 A0430 E0245 K0012
0098T 33227 51605 77071 87496 A0431 E0246 K0014
0099T 33228 51610 77072 87497 A0432 E0247 K0056
0100T 33229 51700 77073 87498 A0433 E0248 K0098
0101T 33230 51701 77074 87500 A0434 E0249 K0105
0102T 33231 51702 77075 87501 A0435 E0250 K0108
0103T 33233 51703 77076 87502 A0436 E0251 K0195
0106T 33234 51705 77077 87503 A0888 E0255 K0455
0107T 33235 51710 77078 87510 A0998 E0256 K0462
0108T 33236 51715 77080 87511 A0999 E0260 K0552
0109T 33237 51720 77081 87512 A4206 E0261 K0601
0110T 33238 51725 77082 87515 A4207 E0265 K0602
0111T 33240 51726 77084 87516 A4208 E0266 K0603
0123T 33241 51727 77261 87517 A4209 E0270 K0604
0124T 33243 51728 77262 87520 A4210 E0271 K0605
0126T 33244 51729 77263 87521 A4211 E0272 K0606
0159T 33249 51736 77280 87522 A4212 E0273 K0607
0163T 33250 51741 77285 87525 A4213 E0274 K0608
0164T 33251 51784 77290 87526 A4215 E0275 K0609
0165T 33254 51785 77295 87527 A4216 E0276 K0669
0169T 33255 51792 77299 87528 A4217 E0277 K0730
0171T 33256 51797 77300 87529 A4218 E0280 K0733
0172T 33257 51798 77301 87530 A4220 E0290 K0738
0174T 33258 51800 77305 87531 A4221 E0291 K0739
0175T 33259 51820 77310 87532 A4222 E0292 K0740
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
0178T 33261 51840 77315 87533 A4223 E0293 K0743
0179T 33262 51841 77321 87534 A4230 E0294 K0744
0180T 33263 51845 77326 87535 A4231 E0295 K0745
0181T 33264 51860 77327 87536 A4232 E0296 K0746
0182T 33265 51865 77328 87537 A4233 E0297 K0800
0183T 33266 51880 77331 87538 A4234 E0300 K0801
0184T 33282 51900 77332 87539 A4235 E0301 K0802
0185T 33284 51920 77333 87540 A4236 E0302 K0806
0186T 33300 51925 77334 87541 A4244 E0303 K0807
0188T 33305 51940 77336 87542 A4245 E0304 K0808
0189T 33310 51960 77338 87550 A4246 E0305 K0812
0190T 33315 51980 77370 87551 A4247 E0310 K0813
0191T 33320 51990 77371 87552 A4248 E0315 K0814
0192T 33321 51992 77372 87555 A4250 E0316 K0815
01953 33322 51999 77373 87556 A4252 E0325 K0816
0195T 33330 52000 77399 87557 A4253 E0326 K0820
0196T 33332 52001 77401 87560 A4255 E0328 K0821
0197T 33335 52005 77402 87561 A4256 E0329 K0822
0198T 33361 52010 77403 87562 A4257 E0350 K0823
01996 33362 52204 77404 87580 A4258 E0352 K0824
0199T 33363 52214 77406 87581 A4259 E0370 K0825
0201T 33364 52224 77407 87582 A4261 E0371 K0826
0202T 33365 52234 77408 87590 A4262 E0372 K0827
0205T 33367 52235 77409 87591 A4263 E0373 K0828
0206T 33368 52240 77411 87592 A4264 E0424 K0829
0207T 33369 52250 77412 87620 A4265 E0425 K0830
0208T 33400 52260 77413 87621 A4266 E0430 K0831
0209T 33401 52265 77414 87622 A4267 E0431 K0835
0210T 33403 52270 77416 87631 A4268 E0433 K0836
0211T 33404 52275 77417 87632 A4269 E0434 K0837
0212T 33405 52276 77418 87633 A4270 E0435 K0838
0219T 33406 52277 77421 87640 A4280 E0439 K0839
0220T 33410 52281 77422 87641 A4281 E0440 K0840
0221T 33411 52282 77423 87650 A4282 E0441 K0841
0222T 33412 52283 77424 87651 A4283 E0442 K0842
0223T 33413 52285 77425 87652 A4284 E0443 K0843
0224T 33414 52287 77427 87653 A4285 E0444 K0848
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
0225T 33415 52290 77431 87660 A4286 E0445 K0849
0226T 33416 52300 77432 87797 A4290 E0446 K0850
0227T 33417 52301 77435 87798 A4300 E0450 K0851
0232T 33420 52305 77469 87799 A4301 E0455 K0852
0233T 33422 52310 77470 87800 A4305 E0457 K0853
0234T 33425 52315 77499 87801 A4306 E0459 K0854
0235T 33426 52317 77520 87802 A4310 E0460 K0855
0236T 33427 52318 77522 87803 A4311 E0461 K0856
0237T 33430 52351 77523 87804 A4312 E0462 K0857
0238T 33460 52400 77525 87807 A4313 E0463 K0858
0239T 33463 52402 77600 87808 A4314 E0464 K0859
0240T 33464 52450 77605 87809 A4315 E0470 K0860
0241T 33465 52500 77610 87810 A4316 E0471 K0861
0243T 33468 52601 77615 87850 A4320 E0472 K0862
0244T 33470 52630 77620 87880 A4321 E0480 K0863
0249T 33471 52640 77750 87899 A4322 E0481 K0864
0253T 33472 52647 77761 87900 A4326 E0482 K0868
0254T 33474 52648 77762 87901 A4327 E0483 K0869
0255T 33475 52649 77763 87902 A4328 E0484 K0870
0260T 33476 52700 77776 87903 A4330 E0485 K0871
0261T 33478 53000 77777 87904 A4331 E0486 K0877
0262T 33496 53010 77778 87905 A4332 E0487 K0878
0263T 33500 53020 77785 87906 A4333 E0500 K0879
0264T 33501 53025 77786 87910 A4334 E0550 K0880
0265T 33502 53040 77787 87912 A4335 E0555 K0884
0266T 33503 53060 77789 87999 A4336 E0560 K0885
0267T 33504 53080 77790 88000 A4338 E0561 K0886
0268T 33505 53085 77799 88005 A4340 E0562 K0890
0269T 33506 53200 78012 88007 A4344 E0565 K0891
0270T 33507 53210 78013 88012 A4346 E0570 K0898
0271T 33508 53215 78014 88014 A4349 E0572 K0899
0272T 33510 53220 78015 88016 A4351 E0574 L0112
0273T 33511 53230 78016 88020 A4352 E0575 L0113
0274T 33512 53235 78018 88025 A4353 E0580 L0120
0275T 33513 53240 78020 88027 A4354 E0585 L0130
0278T 33514 53250 78070 88028 A4355 E0600 L0140
0281T 33516 53260 78071 88029 A4356 E0601 L0150
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
0284T 33517 53265 78072 88036 A4357 E0602 L0160
0285T 33518 53270 78075 88037 A4358 E0603 L0170
0286T 33519 53275 78099 88040 A4360 E0604 L0172
0287T 33521 53400 78102 88045 A4361 E0605 L0174
0288T 33522 53405 78103 88099 A4362 E0606 L0180
0289T 33523 53410 78104 88104 A4363 E0607 L0190
0290T 33530 53415 78110 88106 A4364 E0610 L0200
0291T 33533 53420 78111 88108 A4366 E0615 L0220
0292T 33534 53425 78120 88112 A4367 E0616 L0430
0293T 33535 53430 78121 88120 A4368 E0617 L0450
0294T 33536 53431 78122 88121 A4369 E0618 L0452
0295T 33542 53440 78130 88125 A4371 E0619 L0454
0296T 33545 53442 78135 88130 A4372 E0620 L0456
0297T 33548 53444 78140 88140 A4373 E0621 L0458
0298T 33572 53445 78185 88141 A4375 E0625 L0460
0299T 33600 53446 78190 88142 A4376 E0627 L0462
0300T 33602 53447 78191 88143 A4377 E0628 L0464
0301T 33606 53448 78195 88147 A4378 E0629 L0466
0302T 33608 53449 78199 88148 A4379 E0630 L0468
0303T 33610 53450 78201 88150 A4380 E0635 L0470
0304T 33611 53460 78202 88152 A4381 E0636 L0472
0305T 33612 53500 78205 88153 A4382 E0637 L0480
0306T 33615 53502 78206 88154 A4383 E0638 L0482
0307T 33617 53505 78215 88155 A4384 E0639 L0484
0309T 33619 53510 78216 88160 A4385 E0640 L0486
0310T 33620 53515 78226 88161 A4387 E0641 L0488
0311T 33621 53520 78227 88162 A4388 E0642 L0490
0312T 33622 53600 78230 88164 A4389 E0650 L0491
0313T 33641 53601 78231 88165 A4390 E0651 L0492
0314T 33645 53605 78232 88166 A4391 E0652 L0621
0315T 33647 53620 78258 88167 A4392 E0656 L0622
0316T 33660 53621 78261 88172 A4393 E0657 L0623
0317T 33665 53660 78262 88173 A4394 E0670 L0624
0318T 33670 53661 78264 88174 A4395 E0675 L0625
0319T 33675 53665 78267 88175 A4396 E0691 L0626
0320T 33676 53850 78268 88177 A4397 E0692 L0627
0321T 33677 53852 78270 88182 A4398 E0693 L0628
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
0322T 33681 53855 78271 88184 A4399 E0694 L0629
0323T 33684 53860 78272 88185 A4400 E0700 L0630
0324T 33688 53899 78278 88187 A4402 E0705 L0631
0325T 33690 54000 78282 88188 A4404 E0710 L0632
0326T 33692 54001 78290 88189 A4405 E0720 L0633
0327T 33694 54015 78291 88199 A4406 E0730 L0634
0328T 33697 54050 78299 88230 A4407 E0731 L0635
10021 33702 54055 78300 88233 A4408 E0740 L0636
10022 33710 54056 78305 88235 A4409 E0744 L0637
10040 33720 54057 78306 88237 A4410 E0745 L0638
10060 33722 54060 78315 88239 A4411 E0746 L0639
10061 33724 54065 78320 88240 A4412 E0747 L0640
10080 33726 54100 78350 88241 A4413 E0748 L0700
10081 33730 54105 78351 88245 A4414 E0749 L0710
10120 33732 54110 78399 88248 A4415 E0755 L0810
10121 33735 54111 78414 88249 A4416 E0760 L0820
10140 33736 54112 78428 88261 A4417 E0761 L0830
10160 33737 54115 78445 88262 A4418 E0762 L0859
10180 33750 54120 78451 88263 A4419 E0764 L0861
11000 33755 54125 78452 88264 A4420 E0765 L0970
11001 33762 54130 78453 88267 A4421 E0769 L0972
11004 33764 54135 78454 88269 A4422 E0770 L0974
11005 33766 54150 78456 88271 A4423 E0776 L0976
11006 33767 54160 78457 88272 A4424 E0779 L0978
11008 33768 54161 78458 88273 A4425 E0780 L0980
11010 33770 54162 78459 88274 A4426 E0781 L0982
11011 33771 54163 78466 88275 A4427 E0782 L0984
11012 33774 54164 78468 88280 A4428 E0783 L0999
11042 33775 54200 78469 88283 A4429 E0784 L1000
11043 33776 54205 78472 88285 A4430 E0785 L1001
11044 33777 54220 78473 88289 A4431 E0786 L1005
11045 33778 54230 78481 88291 A4432 E0791 L1010
11046 33779 54231 78483 88299 A4433 E0830 L1020
11047 33780 54235 78491 88300 A4434 E0840 L1025
11055 33781 54240 78492 88302 A4435 E0849 L1030
11056 33782 54250 78494 88304 A4450 E0850 L1040
11057 33783 54300 78496 88305 A4452 E0855 L1050
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
11100 33786 54304 78499 88307 A4455 E0856 L1060
11101 33788 54308 78579 88309 A4456 E0860 L1070
11200 33800 54312 78580 88311 A4458 E0870 L1080
11201 33802 54316 78582 88312 A4461 E0880 L1085
11300 33803 54318 78597 88313 A4463 E0890 L1090
11301 33813 54322 78598 88314 A4465 E0900 L1100
11302 33814 54324 78599 88319 A4466 E0910 L1110
11303 33820 54326 78600 88321 A4470 E0911 L1120
11305 33822 54328 78601 88323 A4480 E0912 L1200
11306 33824 54332 78605 88325 A4481 E0920 L1210
11307 33840 54336 78606 88329 A4483 E0930 L1220
11308 33845 54340 78607 88331 A4490 E0940 L1230
11310 33851 54344 78608 88332 A4495 E0941 L1240
11311 33852 54348 78609 88333 A4500 E0942 L1250
11312 33853 54352 78610 88334 A4510 E0944 L1260
11313 33860 54360 78630 88342 A4520 E0945 L1270
11400 33863 54380 78635 88346 A4550 E0946 L1280
11401 33864 54385 78645 88347 A4554 E0947 L1290
11402 33870 54390 78647 88348 A4556 E0948 L1300
11403 33875 54400 78650 88349 A4557 E0950 L1310
11404 33877 54401 78660 88355 A4558 E0955 L1499
11406 33880 54405 78699 88356 A4559 E0956 L2640
11420 33881 54406 78700 88358 A4561 E0958 L2999
11421 33883 54408 78701 88360 A4562 E0960 L3212
11422 33884 54410 78707 88361 A4565 E0966 L3213
11423 33886 54411 78708 88362 A4566 E0968 L3214
11424 33910 54415 78709 88363 A4570 E0969 L3649
11426 33915 54416 78710 88365 A4575 E0970 L3999
11440 33916 54417 78725 88367 A4580 E0978 L5312
11441 33917 54420 78730 88368 A4590 E0980 L5859
11442 33920 54430 78740 88371 A4595 E0981 L5999
11443 33922 54435 78761 88372 A4600 E0982 L6715
11444 33924 54440 78799 88375 A4601 E0984 L6880
11446 33925 54450 78800 88380 A4604 E0985 L7499
11470 33926 54860 78801 88381 A4605 E0988 L7902
11471 33930 54861 78802 88387 A4606 E0992 L8039
11600 33933 54865 78803 88388 A4608 E1002 L8048
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
11601 33935 54900 78804 88399 A4611 E1003 L8499
11602 33940 54901 78805 88720 A4612 E1004 L8500
11603 33944 55040 78806 88738 A4613 E1005 L8501
11604 33945 55041 78807 88740 A4614 E1006 L8505
11606 33960 55100 78808 88741 A4615 E1007 L8507
11620 33961 55110 78811 88749 A4616 E1008 L8509
11621 33967 55120 78812 89049 A4617 E1009 L8510
11622 33968 55150 78813 89050 A4618 E1010 L8511
11623 33970 55175 78814 89051 A4619 E1011 L8512
11624 33971 55180 78815 89055 A4620 E1014 L8513
11626 33973 55200 78816 89060 A4623 E1029 L8514
11640 33974 55250 78999 89125 A4624 E1030 L8515
11641 33975 55300 79005 89160 A4625 E1031 L8605
11642 33976 55450 79101 89190 A4626 E1035 L8680
11643 33977 55700 79200 89220 A4627 E1036 L8681
11644 33978 55705 79300 89230 A4628 E1037 L8682
11646 33979 55706 79403 89240 A4629 E1038 L8683
11719 33980 55720 79440 89250 A4630 E1039 L8684
11720 33981 55725 79445 89251 A4633 E1050 L8685
11721 33982 55801 79999 89253 A4634 E1060 L8686
11730 33983 55810 80047 89254 A4635 E1070 L8687
11732 33990 55812 80048 89255 A4636 E1083 L8688
11740 33991 55815 80050 89257 A4637 E1084 L8689
11750 33992 55821 80051 89258 A4638 E1085 L8690
11752 33993 55831 80053 89259 A4639 E1086 L8691
11755 33999 55840 80055 89260 A4640 E1087 L8695
11760 34502 55842 80061 89261 A4641 E1088 L8699
11762 34800 55845 80069 89264 A4642 E1089 L9900
11765 34802 55860 80074 89268 A4648 E1090 M0064
11770 34803 55862 80076 89272 A4649 E1092 M0075
11771 34804 55865 80100 89280 A4650 E1093 M0076
11772 34805 55866 80101 89281 A4651 E1100 M0100
11900 34806 55870 80102 89290 A4652 E1110 M0300
11901 34808 55873 80103 89291 A4653 E1130 M0301
11920 34813 55875 80104 89300 A4657 E1140 P2028
11921 34825 55876 80150 89310 A4660 E1150 P2029
11922 34826 55899 80152 89320 A4663 E1160 P2031
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
11950 34830 55920 80154 89321 A4670 E1161 P2033
11951 34831 55970 80156 89322 A4671 E1170 P2038
11952 34832 55980 80157 89325 A4672 E1171 P3000
11954 35081 56405 80158 89329 A4673 E1172 P3001
11960 35082 56420 80160 89330 A4674 E1180 P7001
11976 35180 56440 80162 89331 A4680 E1190 P9010
11980 35182 56441 80164 89335 A4690 E1195 P9011
11981 35184 56442 80166 89342 A4706 E1200 P9012
11982 35188 56501 80168 89343 A4707 E1220 P9016
11983 35189 56515 80170 89344 A4708 E1221 P9017
12001 35190 56605 80172 89346 A4709 E1222 P9019
12002 35306 56606 80173 89352 A4714 E1223 P9020
12004 35390 56620 80174 89353 A4719 E1224 P9021
12005 35400 56625 80176 89354 A4720 E1225 P9022
12006 35500 56630 80178 89356 A4721 E1226 P9023
12007 35537 56631 80182 89398 A4722 E1227 P9031
12011 35538 56632 80184 90281 A4723 E1228 P9032
12013 35572 56633 80185 90283 A4724 E1229 P9033
12014 35600 56634 80186 90284 A4725 E1230 P9034
12015 35637 56637 80188 90287 A4726 E1231 P9035
12016 35638 56700 80190 90288 A4728 E1232 P9036
12017 35646 56800 80192 90291 A4730 E1233 P9037
12018 35654 56805 80194 90296 A4736 E1234 P9038
12020 35681 56810 80195 90371 A4737 E1235 P9039
12021 35682 56820 80196 90375 A4740 E1236 P9040
12031 35683 56821 80197 90376 A4750 E1237 P9041
12032 35685 57000 80198 90378 A4755 E1238 P9043
12034 35686 57010 80200 90384 A4760 E1239 P9044
12035 35697 57020 80201 90385 A4765 E1240 P9045
12036 35700 57022 80202 90386 A4766 E1250 P9046
12037 35800 57023 80299 90389 A4770 E1260 P9047
12041 35820 57061 80400 90393 A4771 E1270 P9048
12042 35840 57065 80402 90396 A4772 E1280 P9050
12044 35860 57100 80406 90399 A4773 E1285 P9051
12045 35870 57105 80408 90460 A4774 E1290 P9052
12046 35875 57106 80410 90461 A4802 E1295 P9053
12047 35876 57107 80412 90471 A4860 E1296 P9054
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
12051 35901 57109 80414 90472 A4870 E1297 P9055
12052 35903 57110 80415 90473 A4890 E1298 P9056
12053 35905 57111 80416 90474 A4911 E1300 P9057
12054 35907 57112 80417 90476 A4913 E1310 P9058
12055 36013 57120 80418 90477 A4918 E1353 P9059
12056 36120 57130 80420 90581 A4927 E1354 P9060
12057 36140 57135 80422 90585 A4928 E1355 P9603
13100 36147 57150 80424 90586 A4929 E1356 P9604
13101 36148 57155 80426 90632 A4930 E1357 P9612
13102 36160 57156 80428 90633 A4931 E1358 P9615
13120 36215 57160 80430 90634 A4932 E1372 Q0035
13121 36216 57170 80432 90636 A5051 E1390 Q0081
13122 36217 57180 80434 90644 A5052 E1391 Q0083
13131 36218 57200 80435 90645 A5053 E1392 Q0084
13132 36221 57210 80436 90646 A5054 E1399 Q0085
13133 36248 57220 80438 90647 A5055 E1405 Q0091
13150 36251 57230 80439 90648 A5056 E1406 Q0092
13151 36252 57240 80440 90649 A5057 E1500 Q0111
13152 36253 57250 80500 90650 A5061 E1510 Q0112
13153 36254 57260 80502 90653 A5062 E1520 Q0113
13160 36260 57265 81000 90654 A5063 E1530 Q0114
14000 36261 57267 81001 90655 A5071 E1540 Q0115
14001 36262 57268 81002 90656 A5072 E1550 Q0138
14020 36299 57270 81003 90657 A5073 E1560 Q0139
14021 36400 57280 81005 90658 A5081 E1570 Q0144
14040 36405 57282 81007 90660 A5082 E1575 Q0162
14041 36406 57283 81015 90661 A5083 E1580 Q0163
14060 36410 57284 81020 90662 A5093 E1590 Q0164
14061 36415 57285 81025 90664 A5102 E1592 Q0165
14301 36416 57287 81050 90666 A5105 E1594 Q0166
14302 36420 57288 81099 90667 A5112 E1600 Q0167
14350 36425 57289 81161 90668 A5113 E1610 Q0168
15002 36430 57291 81200 90669 A5114 E1615 Q0169
15003 36440 57292 81201 90670 A5120 E1620 Q0170
15004 36450 57295 81202 90672 A5121 E1625 Q0171
15005 36455 57296 81203 90675 A5122 E1630 Q0172
15040 36460 57300 81205 90676 A5126 E1632 Q0173
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
15050 36468 57305 81206 90680 A5131 E1634 Q0174
15100 36469 57307 81207 90681 A5200 E1635 Q0175
15101 36481 57308 81208 90685 A5500 E1636 Q0176
15110 36500 57310 81209 90686 A5501 E1637 Q0177
15111 36510 57311 81210 90687 A5503 E1639 Q0178
15115 36511 57320 81211 90688 A5504 E1699 Q0180
15116 36512 57330 81212 90690 A5505 E1700 Q0181
15120 36513 57335 81213 90691 A5506 E1701 Q0478
15121 36514 57400 81214 90692 A5507 E1702 Q0479
15130 36515 57410 81215 90693 A5508 E1820 Q0480
15131 36516 57415 81216 90696 A5510 E1821 Q0481
15135 36522 57420 81217 90698 A5512 E1902 Q0482
15136 36555 57421 81220 90700 A5513 E2000 Q0483
15150 36556 57423 81221 90702 A6000 E2100 Q0484
15151 36563 57425 81222 90703 A6010 E2101 Q0485
15152 36568 57426 81223 90704 A6011 E2120 Q0486
15155 36569 57452 81224 90705 A6021 E2201 Q0487
15156 36575 57454 81225 90706 A6022 E2202 Q0488
15157 36576 57455 81226 90707 A6023 E2203 Q0489
15200 36578 57456 81227 90708 A6024 E2204 Q0490
15201 36580 57460 81228 90710 A6025 E2207 Q0491
15220 36581 57461 81229 90712 A6154 E2208 Q0492
15221 36582 57500 81235 90713 A6196 E2210 Q0493
15240 36583 57505 81240 90714 A6197 E2230 Q0494
15241 36584 57510 81241 90715 A6198 E2231 Q0495
15260 36585 57511 81242 90716 A6199 E2291 Q0496
15261 36589 57513 81243 90717 A6203 E2292 Q0497
15271 36590 57520 81244 90719 A6204 E2293 Q0498
15272 36591 57522 81245 90720 A6205 E2294 Q0499
15273 36592 57530 81250 90721 A6206 E2295 Q0500
15274 36593 57531 81251 90723 A6207 E2300 Q0501
15275 36595 57540 81252 90725 A6208 E2301 Q0502
15276 36596 57545 81253 90727 A6209 E2310 Q0503
15277 36597 57550 81254 90732 A6210 E2311 Q0504
15278 36600 57555 81255 90733 A6211 E2324 Q0505
15570 36620 57556 81256 90734 A6212 E2326 Q0506
15572 36625 57558 81257 90735 A6213 E2327 Q0510
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
15574 36640 57700 81260 90736 A6214 E2328 Q0511
15576 36660 57720 81261 90738 A6215 E2329 Q0512
15600 36680 57800 81262 90739 A6216 E2330 Q0513
15610 36800 58100 81263 90740 A6217 E2331 Q0514
15620 36810 58110 81264 90743 A6218 E2340 Q0515
15630 36815 58120 81265 90744 A6219 E2341 Q1004
15650 36818 58140 81266 90746 A6220 E2342 Q1005
15731 36819 58145 81267 90747 A6221 E2343 Q2004
15732 36821 58146 81268 90748 A6222 E2351 Q2009
15734 36822 58150 81270 90749 A6223 E2358 Q2017
15736 36823 58152 81275 90785 A6224 E2359 Q2026
15738 36825 58180 81280 90791 A6228 E2360 Q2027
15740 36830 58200 81281 90792 A6229 E2361 Q2034
15750 36831 58210 81282 90832 A6230 E2362 Q2035
15756 36832 58240 81290 90833 A6231 E2363 Q2036
15757 36833 58260 81291 90834 A6232 E2364 Q2037
15758 36835 58262 81292 90836 A6233 E2365 Q2038
15760 36860 58263 81293 90837 A6234 E2366 Q2039
15770 36861 58267 81294 90838 A6235 E2367 Q2043
15775 37140 58270 81295 90839 A6236 E2368 Q3001
15776 37145 58275 81296 90840 A6237 E2369 Q3014
15780 37160 58280 81297 90845 A6238 E2370 Q3025
15781 37180 58285 81298 90846 A6239 E2371 Q3026
15782 37181 58290 81299 90847 A6240 E2372 Q3031
15783 37182 58291 81300 90849 A6241 E2378 Q4001
15786 37183 58292 81301 90853 A6242 E2397 Q4002
15787 37185 58293 81302 90863 A6243 E2402 Q4003
15788 37186 58294 81303 90865 A6244 E2500 Q4004
15789 37191 58300 81304 90867 A6245 E2502 Q4005
15792 37192 58301 81310 90868 A6246 E2504 Q4006
15793 37193 58321 81315 90869 A6247 E2506 Q4007
15819 37195 58322 81316 90870 A6248 E2508 Q4008
15830 37197 58323 81317 90875 A6250 E2510 Q4009
15835 37200 58340 81318 90876 A6251 E2511 Q4010
15837 37202 58346 81319 90880 A6252 E2512 Q4011
15838 37204 58353 81321 90882 A6253 E2599 Q4012
15839 37205 58356 81322 90885 A6254 E2601 Q4013
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
15840 37206 58400 81323 90887 A6255 E2602 Q4014
15841 37208 58410 81324 90889 A6256 E2603 Q4015
15842 37210 58520 81325 90899 A6257 E2604 Q4016
15845 37213 58540 81326 90901 A6258 E2605 Q4017
15847 37214 58541 81330 90911 A6259 E2606 Q4018
15850 37216 58542 81331 90935 A6260 E2607 Q4019
15851 37250 58543 81332 90937 A6261 E2608 Q4020
15852 37251 58544 81340 90940 A6262 E2609 Q4021
15860 37600 58545 81341 90945 A6266 E2610 Q4022
15876 37605 58546 81342 90947 A6402 E2611 Q4023
15877 37606 58548 81350 90951 A6403 E2612 Q4024
15920 37607 58550 81355 90952 A6404 E2613 Q4025
15922 37615 58552 81370 90953 A6407 E2614 Q4026
15931 37616 58553 81371 90954 A6410 E2615 Q4027
15933 37617 58554 81372 90955 A6411 E2616 Q4028
15934 37618 58555 81373 90956 A6412 E2617 Q4029
15935 37619 58558 81374 90957 A6413 E2619 Q4030
15936 37788 58559 81375 90958 A6441 E2620 Q4031
15937 37790 58560 81376 90959 A6442 E2621 Q4032
15940 37799 58561 81377 90960 A6443 E2622 Q4033
15941 38100 58562 81378 90961 A6444 E2623 Q4034
15944 38101 58563 81379 90962 A6445 E2624 Q4035
15945 38102 58565 81380 90963 A6446 E2625 Q4036
15946 38115 58570 81381 90964 A6447 E2626 Q4037
15950 38120 58571 81382 90965 A6448 E2627 Q4038
15951 38129 58572 81383 90966 A6449 E2628 Q4039
15952 38200 58573 81400 90967 A6450 E2629 Q4040
15953 38204 58600 81401 90968 A6451 E2630 Q4041
15956 38205 58605 81402 90969 A6452 E2631 Q4042
15958 38206 58611 81403 90970 A6453 E2632 Q4043
15999 38207 58615 81404 90989 A6454 E2633 Q4044
16000 38208 58660 81405 90993 A6455 E8000 Q4045
16020 38209 58662 81406 90997 A6456 E8001 Q4046
16025 38210 58670 81407 90999 A6457 E8002 Q4047
16030 38211 58671 81408 91010 A6501 G0008 Q4048
16035 38212 58700 81479 91013 A6502 G0009 Q4049
16036 38213 58720 81500 91020 A6503 G0010 Q4050
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
17000 38214 58740 81503 91022 A6504 G0027 Q4051
17003 38215 58800 81506 91030 A6505 G0101 Q4074
17004 38230 58805 81508 91034 A6506 G0102 Q4081
17106 38232 58823 81509 91035 A6507 G0103 Q4082
17107 38240 58825 81510 91037 A6508 G0104 Q4100
17108 38241 58900 81511 91038 A6509 G0105 Q4101
17110 38242 58920 81512 91040 A6510 G0106 Q4102
17111 38243 58925 81599 91065 A6511 G0108 Q4103
17250 38300 58940 82000 91110 A6512 G0109 Q4104
17260 38305 58943 82003 91111 A6513 G0117 Q4105
17261 38308 58950 82009 91112 A6530 G0118 Q4106
17262 38380 58951 82010 91117 A6531 G0120 Q4107
17263 38381 58952 82013 91120 A6532 G0121 Q4108
17264 38382 58953 82016 91122 A6533 G0122 Q4110
17266 38550 58954 82017 91132 A6534 G0123 Q4111
17270 38555 58956 82024 91133 A6535 G0124 Q4112
17271 38562 58957 82030 91299 A6536 G0127 Q4113
17272 38564 58958 82040 92002 A6537 G0128 Q4114
17273 38570 58960 82042 92004 A6538 G0129 Q4115
17274 38571 58970 82043 92012 A6539 G0130 Q4116
17276 38572 58974 82044 92014 A6540 G0141 Q4117
17280 38746 58976 82045 92015 A6541 G0143 Q4118
17281 38747 58999 82055 92018 A6544 G0144 Q4119
17282 38780 59000 82075 92019 A6545 G0145 Q4120
17283 38794 59001 82085 92020 A6549 G0147 Q4121
17284 38999 59012 82088 92025 A6550 G0148 Q4122
17286 39000 59015 82101 92060 A7000 G0151 Q4123
17311 39010 59020 82103 92065 A7001 G0152 Q4124
17312 39200 59025 82104 92081 A7002 G0153 Q4125
17313 39220 59030 82105 92082 A7003 G0154 Q4126
17314 39400 59050 82106 92083 A7004 G0155 Q4127
17315 39499 59051 82107 92100 A7005 G0156 Q4128
17340 39501 59070 82108 92132 A7006 G0157 Q4129
17360 39503 59072 82120 92133 A7007 G0158 Q4130
17380 39540 59074 82127 92134 A7008 G0159 Q4131
17999 39541 59076 82128 92140 A7009 G0160 Q4132
19000 39545 59100 82131 92227 A7010 G0161 Q4133
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
19001 39560 59120 82135 92228 A7011 G0162 Q4134
19126 39561 59121 82136 92250 A7012 G0163 Q4135
19260 39599 59130 82139 92260 A7013 G0164 Q4136
19271 40490 59135 82140 92265 A7014 G0166 Q5001
19272 40500 59136 82143 92270 A7015 G0168 Q5002
19291 40510 59140 82145 92275 A7016 G0173 Q5003
19295 40520 59150 82150 92283 A7017 G0175 Q5004
19297 40525 59151 82154 92284 A7018 G0176 Q5005
20005 40527 59160 82157 92285 A7020 G0177 Q5006
20101 40530 59200 82160 92286 A7025 G0179 Q5007
20102 40650 59300 82163 92287 A7026 G0180 Q5008
20103 40652 59320 82164 92310 A7027 G0181 Q5009
20200 40654 59325 82172 92311 A7028 G0182 Q5010
20205 40700 59350 82175 92312 A7029 G0202 Q9951
20206 40701 59400 82180 92313 A7030 G0204 Q9953
20220 40702 59409 82190 92314 A7031 G0206 Q9954
20225 40761 59410 82205 92315 A7032 G0219 Q9955
20240 40799 59412 82232 92316 A7033 G0235 Q9956
20245 40800 59414 82239 92317 A7034 G0237 Q9957
20250 40801 59425 82240 92325 A7035 G0238 Q9958
20251 40804 59426 82247 92326 A7036 G0239 Q9959
20500 40805 59430 82248 92340 A7037 G0245 Q9960
20501 40806 59510 82252 92341 A7038 G0246 Q9961
20520 40808 59514 82261 92342 A7039 G0247 Q9962
20525 40810 59515 82270 92352 A7040 G0248 Q9963
20551 40812 59525 82271 92353 A7041 G0249 Q9964
20552 40814 59610 82272 92354 A7042 G0250 Q9965
20553 40816 59612 82274 92355 A7043 G0251 Q9966
20555 40818 59614 82286 92358 A7044 G0252 Q9967
20612 40819 59618 82300 92370 A7045 G0255 Q9968
20615 40820 59620 82306 92371 A7046 G0257 Q9969
20650 40830 59622 82308 92499 A7501 G0259 R0070
20660 40831 59812 82310 92502 A7502 G0260 R0075
20661 40840 59820 82330 92504 A7503 G0268 R0076
20662 40842 59821 82331 92506 A7504 G0269 S0012
20664 40843 59830 82340 92507 A7505 G0270 S0014
20665 40844 59840 82355 92508 A7506 G0271 S0017
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
20670 40845 59841 82360 92511 A7507 G0275 S0020
20680 40899 59850 82365 92512 A7508 G0278 S0021
20690 41000 59851 82370 92516 A7509 G0281 S0023
20692 41005 59852 82373 92520 A7520 G0282 S0028
20693 41006 59855 82374 92526 A7521 G0283 S0030
20694 41007 59856 82375 92531 A7522 G0288 S0032
20696 41008 59857 82376 92532 A7523 G0293 S0034
20697 41009 59866 82378 92533 A7524 G0294 S0039
20816 41010 59870 82379 92534 A7525 G0295 S0040
20822 41015 59871 82380 92540 A7526 G0302 S0073
20900 41016 59897 82382 92541 A7527 G0303 S0074
20902 41017 59899 82383 92542 A8000 G0304 S0077
20910 41018 60000 82384 92543 A8001 G0305 S0078
20912 41019 60100 82387 92544 A8002 G0306 S0080
20920 41100 60200 82390 92545 A8003 G0307 S0081
20922 41105 60210 82397 92546 A8004 G0328 S0088
20924 41108 60212 82415 92547 A9150 G0329 S0090
20926 41110 60220 82435 92548 A9152 G0333 S0091
20930 41112 60225 82436 92550 A9153 G0337 S0092
20931 41113 60240 82438 92551 A9155 G0339 S0093
20936 41114 60252 82441 92552 A9180 G0340 S0104
20937 41115 60254 82465 92553 A9270 G0341 S0106
20938 41116 60270 82480 92555 A9272 G0342 S0108
20950 41120 60271 82482 92556 A9273 G0343 S0109
20955 41130 60280 82485 92557 A9274 G0364 S0117
20956 41135 60281 82486 92558 A9275 G0365 S0119
20957 41140 60300 82487 92559 A9276 G0372 S0122
20962 41145 60500 82488 92560 A9277 G0378 S0126
20969 41150 60502 82489 92561 A9278 G0379 S0128
20970 41153 60505 82491 92562 A9279 G0389 S0132
20972 41155 60512 82492 92563 A9280 G0390 S0136
20974 41250 60520 82495 92564 A9281 G0396 S0137
20975 41251 60521 82507 92565 A9282 G0397 S0138
20979 41252 60522 82520 92567 A9283 G0398 S0139
20985 41500 60600 82523 92568 A9284 G0399 S0140
20999 41510 60605 82525 92570 A9300 G0400 S0142
21011 41512 60699 82528 92571 A9500 G0402 S0145
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
21012 41520 61000 82530 92572 A9501 G0403 S0148
21013 41530 61001 82533 92575 A9502 G0404 S0155
21014 41599 61020 82540 92576 A9503 G0405 S0156
21015 41800 61026 82541 92577 A9504 G0406 S0157
21016 41805 61050 82542 92579 A9505 G0407 S0160
21025 41806 61055 82543 92582 A9507 G0408 S0164
21026 41820 61070 82544 92583 A9508 G0409 S0166
21029 41821 61105 82550 92584 A9509 G0410 S0169
21032 41822 61107 82552 92585 A9510 G0411 S0170
21034 41823 61108 82553 92586 A9512 G0412 S0171
21040 41825 61120 82554 92587 A9516 G0413 S0172
21044 41826 61140 82565 92588 A9517 G0414 S0174
21045 41827 61150 82570 92590 A9521 G0415 S0175
21046 41828 61151 82575 92591 A9524 G0416 S0176
21047 41830 61156 82585 92592 A9526 G0417 S0177
21048 41850 61210 82595 92593 A9527 G0418 S0178
21049 41870 61215 82600 92594 A9528 G0419 S0179
21076 41872 61253 82607 92595 A9529 G0420 S0182
21079 41874 61304 82608 92596 A9530 G0421 S0183
21080 41899 61305 82610 92597 A9531 G0422 S0187
21081 42000 61312 82615 92601 A9532 G0423 S0189
21082 42100 61313 82626 92602 A9536 G0424 S0190
21083 42104 61314 82627 92603 A9537 G0425 S0191
21084 42106 61315 82633 92604 A9538 G0426 S0194
21085 42107 61316 82634 92605 A9539 G0427 S0195
21087 42120 61320 82638 92606 A9540 G0428 S0197
21088 42140 61321 82646 92607 A9541 G0429 S0199
21089 42145 61322 82649 92608 A9542 G0431 S0201
21100 42160 61323 82651 92609 A9543 G0432 S0207
21110 42180 61343 82652 92610 A9544 G0433 S0208
21120 42182 61345 82654 92611 A9545 G0434 S0209
21121 42200 61440 82656 92612 A9546 G0435 S0215
21122 42205 61450 82657 92613 A9547 G0436 S0220
21123 42210 61458 82658 92614 A9548 G0437 S0221
21125 42215 61460 82664 92615 A9550 G0438 S0250
21127 42220 61470 82666 92616 A9551 G0439 S0255
21137 42225 61480 82668 92617 A9552 G0442 S0257
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
21138 42226 61500 82670 92618 A9553 G0443 S0260
21139 42227 61501 82671 92620 A9554 G0444 S0265
21141 42235 61510 82672 92621 A9555 G0445 S0270
21142 42260 61512 82677 92625 A9556 G0446 S0271
21143 42280 61514 82679 92626 A9557 G0447 S0272
21145 42281 61516 82690 92627 A9558 G0448 S0273
21146 42299 61517 82693 92630 A9559 G0451 S0274
21147 42300 61518 82696 92633 A9560 G0452 S0280
21150 42305 61519 82705 92640 A9561 G0453 S0281
21151 42310 61520 82710 92700 A9562 G0454 S0302
21154 42320 61521 82715 92920 A9563 G0455 S0310
21155 42330 61522 82725 92921 A9564 G0456 S0315
21159 42335 61524 82726 92924 A9566 G0457 S0316
21160 42400 61526 82728 92925 A9567 G0458 S0317
21172 42405 61530 82731 92928 A9568 G3001 S0320
21175 42408 61531 82735 92929 A9569 G9001 S0340
21179 42409 61533 82742 92933 A9570 G9002 S0341
21180 42450 61534 82746 92934 A9571 G9003 S0342
21181 42500 61535 82747 92937 A9572 G9004 S0353
21182 42505 61536 82757 92938 A9576 G9005 S0354
21183 42507 61537 82759 92941 A9577 G9006 S0390
21184 42508 61538 82760 92943 A9578 G9007 S0395
21188 42509 61539 82775 92944 A9579 G9008 S0400
21193 42510 61540 82776 92950 A9580 G9009 S0500
21194 42550 61541 82777 92953 A9581 G9010 S0504
21195 42600 61542 82784 92960 A9582 G9011 S0506
21196 42650 61543 82785 92961 A9583 G9012 S0508
21198 42660 61544 82787 92970 A9584 G9143 S0510
21199 42665 61545 82800 92971 A9585 G9147 S0512
21206 42699 61546 82803 92973 A9586 G9156 S0514
21208 42700 61548 82805 92974 A9600 G9157 S0515
21209 42720 61550 82810 92975 A9604 H0001 S0516
21210 42725 61552 82820 92977 A9698 H0002 S0518
21215 42800 61556 82930 92978 A9699 H0003 S0580
21230 42802 61557 82938 92979 A9700 H0004 S0581
21235 42804 61558 82941 92986 A9900 H0005 S0590
21244 42806 61559 82943 92987 A9901 H0006 S0592
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
21245 42808 61563 82945 92990 A9999 H0007 S0595
21246 42809 61566 82946 92992 B4034 H0008 S0596
21248 42820 61567 82947 92993 B4035 H0009 S0601
21249 42821 61570 82948 92997 B4036 H0010 S0610
21260 42825 61571 82950 92998 B4081 H0011 S0612
21261 42826 61575 82951 93000 B4082 H0012 S0613
21263 42830 61576 82952 93005 B4083 H0013 S0618
21275 42831 61582 82953 93010 B4087 H0014 S0620
21299 42835 61583 82955 93015 B4088 H0015 S0621
21310 42836 61586 82960 93016 B4100 H0016 S0622
21315 42842 61598 82962 93017 B4102 H0017 S0630
21320 42844 61600 82963 93018 B4103 H0018 S0800
21325 42845 61601 82965 93024 B4104 H0019 S0810
21330 42860 61605 82975 93025 B4149 H0020 S0812
21335 42870 61606 82977 93040 B4150 H0021 S1001
21336 42890 61607 82978 93041 B4152 H0022 S1002
21337 42892 61608 82979 93042 B4153 H0023 S1015
21338 42894 61609 82980 93224 B4154 H0024 S1016
21339 42900 61610 82985 93225 B4155 H0025 S1030
21340 42950 61611 83001 93226 B4157 H0026 S1031
21343 42953 61612 83002 93227 B4158 H0027 S1040
21344 42955 61615 83003 93228 B4159 H0028 S1090
21345 42960 61616 83008 93229 B4160 H0029 S2053
21346 42961 61618 83009 93268 B4161 H0030 S2054
21347 42962 61619 83010 93270 B4162 H0031 S2055
21348 42970 61623 83012 93271 B4164 H0032 S2060
21421 42971 61624 83013 93272 B4168 H0033 S2061
21422 42972 61626 83014 93278 B4172 H0034 S2065
21423 42999 61630 83015 93279 B4176 H0035 S2070
21431 43020 61635 83018 93280 B4178 H0036 S2079
21432 43030 61640 83020 93281 B4180 H0037 S2080
21433 43045 61641 83021 93282 B4185 H0038 S2083
21435 43100 61642 83026 93283 B4189 H0039 S2095
21436 43101 61680 83030 93284 B4193 H0040 S2102
21440 43107 61682 83033 93285 B4197 H0041 S2103
21445 43108 61684 83036 93286 B4199 H0042 S2107
21450 43112 61686 83037 93287 B4216 H0043 S2112
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
21451 43113 61690 83045 93288 B4220 H0044 S2115
21452 43116 61692 83050 93289 B4222 H0045 S2117
21453 43117 61697 83051 93290 B4224 H0046 S2118
21454 43118 61698 83055 93291 B5000 H0047 S2120
21461 43121 61700 83060 93292 B5100 H0048 S2140
21462 43122 61702 83065 93293 B5200 H0049 S2142
21470 43123 61703 83068 93294 B9000 H0050 S2150
21495 43124 61705 83069 93295 B9002 H1000 S2152
21497 43130 61708 83070 93296 B9004 H1001 S2202
21499 43135 61710 83071 93297 B9006 H1002 S2205
21501 43200 61711 83080 93298 B9998 H1003 S2206
21502 43201 61720 83088 93299 B9999 H1004 S2207
21510 43202 61735 83090 93303 D0120 H1005 S2208
21550 43204 61750 83150 93304 D0140 H1010 S2209
21552 43205 61751 83491 93306 D0145 H1011 S2225
21554 43206 61760 83497 93307 D0150 H2000 S2230
21555 43215 61770 83498 93308 D0160 H2001 S2235
21556 43216 61781 83499 93312 D0170 H2010 S2260
21557 43217 61782 83500 93313 D0180 H2011 S2265
21558 43219 61783 83505 93314 D0190 H2012 S2266
21600 43220 61796 83516 93315 D0191 H2013 S2267
21610 43226 61797 83518 93316 D0210 H2014 S2300
21620 43227 61798 83519 93317 D0220 H2015 S2325
21627 43228 61799 83520 93318 D0230 H2016 S2340
21630 43231 61800 83525 93320 D0240 H2017 S2341
21632 43232 61850 83527 93321 D0250 H2018 S2342
21685 43235 61860 83528 93325 D0260 H2019 S2348
21720 43236 61864 83540 93350 D0270 H2020 S2350
21725 43237 61868 83550 93351 D0272 H2021 S2351
21740 43238 61870 83570 93352 D0273 H2022 S2360
21742 43239 61875 83582 93451 D0274 H2023 S2361
21743 43240 61886 83586 93452 D0277 H2024 S2400
21750 43241 62000 83593 93453 D0290 H2025 S2401
21800 43242 62005 83605 93454 D0310 H2026 S2402
21805 43243 62010 83615 93455 D0320 H2027 S2403
21810 43244 62100 83625 93456 D0321 H2028 S2404
21820 43245 62115 83630 93457 D0322 H2029 S2405
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
21825 43246 62116 83631 93458 D0330 H2030 S2409
21899 43247 62117 83632 93459 D0340 H2031 S2411
21920 43248 62120 83633 93460 D0350 H2032 S2900
21925 43249 62121 83634 93461 D0363 H2033 S3000
21930 43250 62140 83655 93462 D0364 H2034 S3005
21931 43251 62141 83661 93463 D0365 H2035 S3600
21932 43252 62142 83662 93464 D0366 H2036 S3601
21933 43255 62143 83663 93503 D0367 H2037 S3620
21935 43256 62145 83664 93505 D0368 J0120 S3625
21936 43257 62146 83670 93530 D0369 J0129 S3626
22010 43258 62147 83690 93531 D0370 J0130 S3630
22015 43259 62148 83695 93532 D0371 J0131 S3645
22100 43260 62160 83698 93533 D0380 J0132 S3650
22101 43261 62161 83700 93561 D0381 J0133 S3652
22102 43262 62162 83701 93562 D0382 J0135 S3655
22103 43263 62163 83704 93563 D0383 J0150 S3708
22110 43264 62164 83718 93564 D0384 J0152 S3721
22112 43265 62165 83719 93565 D0385 J0171 S3722
22114 43267 62180 83721 93566 D0386 J0178 S3800
22116 43268 62190 83727 93567 D0391 J0180 S3833
22206 43269 62192 83735 93568 D0415 J0190 S3834
22207 43271 62194 83775 93571 D0416 J0200 S3840
22208 43272 62200 83785 93572 D0417 J0205 S3841
22210 43273 62201 83788 93580 D0418 J0207 S3842
22212 43279 62220 83789 93581 D0421 J0210 S3844
22214 43280 62223 83805 93600 D0425 J0215 S3845
22216 43281 62225 83825 93602 D0431 J0220 S3846
22220 43282 62230 83835 93603 D0460 J0221 S3849
22222 43283 62252 83840 93609 D0470 J0256 S3850
22224 43300 62256 83857 93610 D0472 J0257 S3852
22226 43305 62258 83858 93612 D0473 J0270 S3853
22305 43310 62263 83861 93613 D0474 J0275 S3854
22310 43312 62264 83864 93615 D0475 J0278 S3855
22315 43313 62267 83866 93616 D0476 J0280 S3861
22318 43314 62268 83872 93618 D0477 J0282 S3865
22319 43320 62269 83873 93619 D0478 J0285 S3866
22325 43325 62270 83874 93620 D0479 J0287 S3870
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
22326 43327 62272 83876 93621 D0480 J0288 S3890
22327 43328 62273 83880 93622 D0481 J0289 S3900
22328 43330 62280 83883 93623 D0482 J0290 S3902
22505 43331 62281 83885 93624 D0483 J0295 S3904
22520 43332 62282 83887 93631 D0484 J0300 S4005
22521 43333 62284 83915 93640 D0485 J0330 S4011
22522 43334 62287 83916 93641 D0486 J0348 S4013
22523 43335 62290 83918 93642 D0502 J0350 S4014
22524 43336 62291 83919 93650 D0999 J0360 S4015
22525 43337 62292 83921 93653 D1110 J0364 S4016
22526 43338 62294 83925 93654 D1120 J0365 S4017
22527 43340 62310 83930 93655 D1206 J0380 S4018
22532 43341 62311 83935 93656 D1208 J0390 S4020
22533 43350 62318 83937 93657 D1310 J0395 S4021
22534 43351 62319 83945 93660 D1320 J0400 S4022
22548 43352 62350 83950 93662 D1330 J0456 S4023
22551 43360 62351 83951 93668 D1351 J0461 S4025
22552 43361 62355 83970 93701 D1352 J0470 S4026
22554 43400 62360 83986 93724 D1510 J0475 S4027
22556 43401 62361 83987 93740 D1515 J0476 S4028
22558 43405 62362 83992 93745 D1520 J0480 S4030
22585 43410 62365 83993 93750 D1525 J0485 S4031
22586 43415 62367 84022 93770 D1550 J0490 S4035
22590 43420 62368 84030 93784 D1555 J0500 S4037
22595 43425 62369 84035 93786 D2140 J0515 S4040
22600 43450 62370 84060 93788 D2150 J0520 S4042
22610 43453 63001 84061 93790 D2160 J0558 S4981
22612 43456 63003 84066 93797 D2161 J0561 S4989
22614 43458 63005 84075 93798 D2330 J0583 S4990
22630 43460 63011 84078 93799 D2331 J0585 S4991
22632 43496 63012 84080 93880 D2332 J0586 S4993
22633 43499 63015 84081 93882 D2335 J0587 S4995
22634 43500 63016 84085 93886 D2390 J0588 S5000
22800 43501 63017 84087 93888 D2391 J0592 S5001
22802 43502 63045 84100 93890 D2392 J0594 S5010
22804 43510 63046 84105 93892 D2393 J0595 S5011
22808 43520 63047 84106 93893 D2394 J0597 S5012
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
22810 43605 63048 84110 93922 D2410 J0598 S5013
22812 43610 63050 84112 93923 D2420 J0600 S5014
22818 43611 63051 84119 93924 D2430 J0610 S5035
22819 43620 63055 84120 93925 D2510 J0620 S5036
22830 43621 63056 84126 93926 D2520 J0630 S5100
22840 43622 63057 84127 93930 D2530 J0636 S5101
22841 43631 63064 84132 93931 D2542 J0637 S5102
22842 43632 63066 84133 93965 D2543 J0638 S5105
22843 43633 63075 84134 93970 D2544 J0640 S5108
22844 43634 63076 84135 93971 D2610 J0641 S5109
22845 43635 63077 84138 93975 D2620 J0670 S5110
22846 43640 63078 84140 93976 D2630 J0690 S5111
22847 43641 63081 84143 93978 D2642 J0692 S5115
22848 43644 63082 84144 93979 D2643 J0694 S5116
22849 43645 63085 84145 93980 D2644 J0696 S5120
22850 43647 63086 84146 93981 D2650 J0697 S5121
22851 43648 63087 84150 93982 D2651 J0698 S5125
22852 43651 63088 84152 93990 D2652 J0702 S5126
22855 43652 63090 84153 93998 D2662 J0706 S5130
22856 43653 63091 84154 94002 D2663 J0710 S5131
22857 43752 63101 84155 94003 D2664 J0712 S5135
22861 43753 63102 84156 94004 D2710 J0713 S5136
22862 43754 63103 84157 94005 D2712 J0715 S5140
22864 43755 63170 84160 94010 D2720 J0716 S5141
22865 43756 63172 84163 94011 D2721 J0718 S5145
22899 43757 63173 84165 94012 D2722 J0720 S5146
22900 43760 63180 84166 94013 D2740 J0725 S5150
22901 43761 63182 84181 94014 D2750 J0735 S5151
22902 43770 63185 84182 94015 D2751 J0740 S5160
22903 43771 63190 84202 94016 D2752 J0743 S5161
22904 43772 63194 84203 94060 D2780 J0744 S5162
22905 43773 63195 84206 94070 D2781 J0745 S5165
22999 43774 63196 84207 94150 D2782 J0760 S5170
23000 43775 63197 84210 94200 D2783 J0770 S5175
23030 43800 63198 84220 94250 D2790 J0775 S5180
23395 43810 63199 84228 94375 D2791 J0780 S5181
23397 43820 63200 84233 94400 D2792 J0795 S5185
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
23405 43825 63250 84234 94450 D2794 J0800 S5190
23406 43830 63251 84235 94452 D2799 J0833 S5199
23900 43831 63252 84238 94453 D2910 J0834 S5497
23929 43832 63265 84244 94610 D2915 J0840 S5498
24301 43840 63266 84252 94620 D2920 J0850 S5501
24305 43842 63267 84255 94621 D2929 J0878 S5502
24310 43843 63268 84260 94640 D2930 J0881 S5517
24320 43845 63270 84270 94642 D2931 J0882 S5518
25210 43846 63271 84275 94644 D2932 J0885 S5520
25260 43847 63272 84285 94645 D2933 J0886 S5521
25263 43848 63273 84295 94660 D2934 J0890 S5522
25265 43850 63275 84300 94662 D2940 J0894 S5523
25270 43855 63276 84302 94664 D2950 J0895 S5550
25272 43860 63277 84305 94667 D2951 J0897 S5551
25274 43865 63278 84307 94668 D2952 J0900 S5552
25280 43870 63280 84311 94680 D2953 J0945 S5553
25290 43880 63281 84315 94681 D2954 J1000 S5560
25295 43881 63282 84375 94690 D2955 J1020 S5561
25310 43882 63283 84376 94726 D2957 J1030 S5565
25312 43886 63285 84377 94727 D2960 J1040 S5566
26010 43887 63286 84378 94728 D2961 J1050 S5570
26011 43888 63287 84379 94729 D2962 J1060 S5571
26020 43999 63290 84392 94750 D2970 J1070 S8030
26034 44005 63295 84402 94760 D2971 J1080 S8035
26035 44010 63300 84403 94761 D2975 J1094 S8037
26055 44015 63301 84425 94762 D2980 J1100 S8040
26060 44020 63302 84430 94770 D2981 J1110 S8042
26080 44021 63303 84431 94772 D2982 J1120 S8055
26110 44025 63304 84432 94774 D2983 J1160 S8080
26111 44050 63305 84436 94775 D2990 J1162 S8085
26113 44055 63306 84437 94776 D2999 J1165 S8092
26115 44100 63307 84439 94777 D3110 J1170 S8096
26116 44110 63308 84442 94780 D3120 J1180 S8097
26117 44111 63600 84443 94781 D3220 J1190 S8100
26118 44120 63610 84445 94799 D3221 J1200 S8101
26125 44121 63615 84446 95004 D3222 J1205 S8110
26135 44125 63620 84449 95012 D3230 J1212 S8120
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
26140 44126 63621 84450 95017 D3240 J1230 S8121
26145 44127 63650 84460 95018 D3310 J1240 S8130
26160 44128 63655 84466 95024 D3320 J1245 S8131
26170 44130 63661 84478 95027 D3330 J1250 S8185
26180 44132 63662 84479 95028 D3331 J1260 S8186
26200 44133 63663 84480 95044 D3332 J1265 S8189
26205 44135 63664 84481 95052 D3333 J1267 S8210
26210 44136 63685 84482 95056 D3346 J1270 S8262
26215 44137 63688 84484 95060 D3347 J1290 S8265
26230 44139 63700 84485 95065 D3348 J1300 S8270
26235 44140 63702 84488 95070 D3351 J1320 S8301
26236 44141 63704 84490 95071 D3352 J1324 S8415
26250 44143 63706 84510 95076 D3353 J1325 S8420
26260 44144 63707 84512 95079 D3354 J1327 S8421
26262 44145 63709 84520 95115 D3410 J1330 S8422
26320 44146 63710 84525 95117 D3421 J1335 S8423
26350 44147 63740 84540 95120 D3425 J1364 S8424
26352 44150 63741 84545 95125 D3426 J1380 S8425
26356 44151 63744 84550 95130 D3430 J1410 S8426
26357 44155 63746 84560 95131 D3450 J1430 S8427
26358 44156 64420 84577 95132 D3460 J1435 S8428
26370 44157 64517 84578 95133 D3470 J1436 S8429
26372 44158 64530 84580 95134 D3910 J1438 S8430
26373 44160 64550 84583 95144 D3920 J1440 S8431
26390 44180 64553 84585 95145 D3950 J1441 S8450
26392 44186 64555 84586 95146 D3999 J1450 S8451
26410 44187 64565 84588 95147 D4210 J1451 S8452
26412 44188 64566 84590 95148 D4211 J1452 S8460
26415 44202 64575 84591 95149 D4212 J1453 S8490
26416 44203 64580 84597 95165 D4230 J1455 S8930
26418 44204 64581 84600 95170 D4231 J1457 S8940
26420 44205 64585 84620 95180 D4240 J1458 S8948
26426 44206 64590 84630 95199 D4241 J1459 S8950
26428 44207 64595 84681 95250 D4245 J1460 S8990
26432 44208 64600 84702 95251 D4249 J1557 S8999
26433 44210 64611 84703 95782 D4260 J1559 S9001
26434 44211 64612 84704 95783 D4261 J1560 S9007
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
26437 44212 64615 84830 95800 D4263 J1561 S9015
26440 44213 64620 84999 95801 D4264 J1562 S9024
26442 44227 64630 85002 95803 D4265 J1566 S9025
26445 44300 64650 85004 95805 D4266 J1568 S9034
26449 44310 64653 85007 95806 D4267 J1569 S9055
26450 44312 64680 85008 95807 D4268 J1570 S9056
26455 44314 64681 85009 95808 D4270 J1571 S9061
26460 44316 64702 85013 95810 D4273 J1572 S9083
26471 44320 64704 85014 95811 D4274 J1573 S9088
26474 44322 64708 85018 95812 D4275 J1580 S9090
26476 44340 64716 85025 95813 D4276 J1590 S9097
26477 44345 64722 85027 95816 D4277 J1595 S9098
26478 44346 64726 85032 95819 D4278 J1599 S9110
26479 44360 64727 85041 95822 D4320 J1600 S9117
26480 44361 64752 85044 95824 D4321 J1610 S9122
26483 44363 64755 85045 95827 D4341 J1620 S9123
26485 44364 64760 85046 95829 D4342 J1626 S9124
26489 44365 64771 85048 95830 D4355 J1630 S9125
26490 44366 64772 85049 95831 D4381 J1631 S9126
26492 44369 64774 85055 95832 D4910 J1640 S9127
26494 44370 64776 85060 95833 D4920 J1642 S9128
26496 44372 64778 85097 95834 D4999 J1644 S9129
26497 44373 64782 85130 95851 D5110 J1645 S9131
26498 44376 64783 85170 95852 D5120 J1650 S9140
26499 44377 64784 85175 95857 D5130 J1652 S9141
26500 44378 64787 85210 95860 D5140 J1655 S9145
26502 44379 64788 85220 95861 D5211 J1670 S9150
26510 44380 64790 85230 95863 D5212 J1675 S9152
26520 44382 64792 85240 95864 D5213 J1700 S9208
26525 44383 64795 85244 95865 D5214 J1710 S9209
26530 44385 64820 85245 95867 D5225 J1720 S9211
26531 44386 64832 85246 95868 D5226 J1725 S9212
26535 44388 64837 85247 95869 D5281 J1730 S9213
26536 44389 64856 85250 95870 D5410 J1740 S9214
26540 44390 64857 85260 95872 D5411 J1741 S9325
26541 44391 64859 85270 95873 D5421 J1742 S9326
26542 44392 64864 85280 95874 D5422 J1743 S9327
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
26545 44393 64865 85290 95875 D5510 J1744 S9328
26548 44394 64866 85291 95905 D5520 J1745 S9329
26555 44397 64868 85292 95921 D5610 J1750 S9330
26556 44500 64870 85293 95922 D5620 J1756 S9331
26560 44602 64872 85300 95923 D5630 J1786 S9335
26561 44603 64874 85301 95924 D5640 J1790 S9336
26562 44604 64876 85302 95925 D5650 J1800 S9338
26565 44605 64885 85303 95926 D5660 J1810 S9339
26567 44615 64886 85305 95927 D5670 J1815 S9340
26568 44620 64890 85306 95928 D5671 J1817 S9341
26587 44625 64891 85307 95929 D5710 J1826 S9342
26590 44626 64892 85335 95930 D5711 J1830 S9343
26591 44640 64893 85337 95933 D5720 J1835 S9345
26593 44650 64895 85345 95937 D5721 J1840 S9346
26596 44660 64896 85347 95938 D5730 J1850 S9347
26600 44661 64897 85348 95939 D5731 J1885 S9348
26605 44680 64898 85360 95940 D5740 J1890 S9349
26607 44700 64901 85362 95941 D5741 J1930 S9351
26608 44701 64902 85366 95943 D5750 J1931 S9353
26615 44705 64905 85370 95950 D5751 J1940 S9355
26670 44715 64907 85378 95951 D5760 J1945 S9357
26675 44720 64910 85379 95953 D5761 J1950 S9359
26676 44721 64911 85380 95954 D5810 J1953 S9361
26685 44799 64999 85384 95955 D5811 J1955 S9363
26686 44800 65757 85385 95956 D5820 J1956 S9364
26700 44820 65760 85390 95957 D5821 J1960 S9365
26705 44850 65765 85396 95958 D5850 J1980 S9366
26706 44899 65767 85397 95961 D5851 J1990 S9367
26715 44900 65771 85400 95962 D5860 J2001 S9368
26720 44901 66990 85410 95965 D5861 J2010 S9370
26725 44950 67221 85415 95966 D5862 J2020 S9372
26727 44955 67225 85420 95967 D5867 J2060 S9373
26735 44960 67320 85421 95970 D5875 J2150 S9374
26740 44970 67340 85441 95971 D5899 J2170 S9375
26742 45000 67800 85445 95972 D5911 J2175 S9376
26746 45005 67801 85460 95973 D5912 J2180 S9377
26750 45020 67805 85461 95974 D5913 J2185 S9379
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
26755 45100 67808 85475 95975 D5914 J2210 S9381
26756 45108 69090 85520 95978 D5915 J2212 S9401
26765 45110 69100 85525 95979 D5916 J2248 S9430
26770 45111 69120 85530 95980 D5919 J2250 S9433
26775 45112 69150 85536 95981 D5922 J2260 S9434
26776 45113 69155 85540 95982 D5923 J2265 S9435
26785 45114 69210 85547 95990 D5924 J2270 S9436
26843 45116 69399 85549 95991 D5925 J2271 S9437
26844 45119 69710 85555 95992 D5926 J2275 S9438
26850 45120 69990 85557 95999 D5927 J2278 S9439
26852 45121 70010 85576 96000 D5928 J2280 S9441
26860 45123 70015 85597 96001 D5929 J2300 S9442
26861 45126 70100 85598 96002 D5931 J2310 S9443
26862 45130 70110 85610 96003 D5932 J2315 S9444
26863 45135 70134 85611 96004 D5933 J2320 S9445
26910 45136 70140 85612 96020 D5934 J2323 S9446
26951 45150 70150 85613 96040 D5935 J2325 S9447
26952 45160 70160 85635 96101 D5936 J2353 S9449
26989 45171 70170 85651 96102 D5937 J2354 S9451
26990 45172 70200 85652 96103 D5951 J2355 S9452
26991 45190 70210 85660 96105 D5952 J2357 S9453
26992 45300 70220 85670 96110 D5953 J2358 S9454
27075 45303 70240 85675 96111 D5954 J2360 S9455
27076 45305 70250 85705 96116 D5955 J2370 S9460
27077 45307 70260 85730 96118 D5958 J2400 S9465
27080 45308 70300 85732 96119 D5959 J2405 S9470
27158 45309 70310 85810 96120 D5960 J2410 S9472
27193 45315 70320 85999 96125 D5982 J2425 S9473
27194 45317 70328 86000 96150 D5983 J2426 S9474
27200 45320 70330 86001 96151 D5984 J2430 S9475
27202 45321 70350 86003 96152 D5985 J2440 S9476
27215 45327 70355 86005 96153 D5986 J2460 S9480
27216 45330 70360 86021 96154 D5987 J2469 S9482
27217 45331 70370 86022 96155 D5988 J2501 S9484
27218 45332 70371 86023 96360 D5991 J2503 S9485
27275 45333 70373 86038 96361 D5992 J2504 S9490
27282 45334 70380 86039 96365 D5993 J2505 S9494
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
27290 45335 70390 86060 96366 D5999 J2507 S9497
27358 45337 70450 86063 96367 D6010 J2510 S9500
27391 45338 70460 86077 96368 D6012 J2513 S9501
27392 45339 70470 86078 96369 D6040 J2515 S9502
27394 45340 70480 86079 96370 D6050 J2540 S9503
27395 45341 70481 86140 96371 D6051 J2543 S9504
27658 45342 70482 86141 96372 D6053 J2545 S9529
27659 45345 70486 86146 96373 D6054 J2550 S9537
27664 45355 70487 86147 96374 D6055 J2560 S9538
27665 45378 70488 86148 96375 D6056 J2562 S9542
27680 45379 70490 86152 96376 D6057 J2590 S9558
27692 45380 70491 86153 96379 D6058 J2597 S9559
28001 45381 70492 86155 96401 D6059 J2650 S9560
28002 45382 70496 86156 96402 D6060 J2670 S9562
28003 45383 70498 86157 96405 D6061 J2675 S9590
28005 45384 70540 86160 96406 D6062 J2680 S9810
28010 45385 70542 86161 96409 D6063 J2690 S9900
28011 45386 70543 86162 96411 D6064 J2700 S9970
28020 45387 70544 86171 96413 D6065 J2710 S9975
28022 45391 70545 86185 96415 D6066 J2720 S9976
28024 45392 70546 86200 96416 D6067 J2724 S9977
28070 45395 70547 86215 96417 D6068 J2725 S9981
28072 45397 70548 86225 96420 D6069 J2730 S9982
28080 45400 70549 86226 96422 D6070 J2760 S9986
28092 45402 70551 86235 96423 D6071 J2765 S9988
28104 45499 70552 86243 96425 D6072 J2770 S9989
28106 45500 70553 86255 96440 D6073 J2778 S9990
28107 45505 70557 86256 96446 D6074 J2780 S9991
28108 45520 70558 86277 96450 D6075 J2783 S9992
28126 45540 70559 86280 96521 D6076 J2785 S9994
28140 45541 71010 86294 96522 D6077 J2788 S9996
28150 45550 71015 86300 96523 D6078 J2790 S9999
28153 45560 71020 86301 96542 D6079 J2791 T1000
28160 45562 71021 86304 96549 D6080 J2792 T1001
28171 45563 71022 86305 96567 D6090 J2793 T1002
28173 45800 71023 86308 96570 D6091 J2794 T1003
28175 45805 71030 86309 96571 D6092 J2795 T1004
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
28200 45820 71034 86310 96900 D6093 J2796 T1005
28202 45825 71035 86316 96902 D6094 J2800 T1006
28208 45900 71100 86317 96904 D6095 J2805 T1007
28210 45905 71101 86318 96910 D6100 J2810 T1009
28232 45910 71110 86320 96912 D6101 J2820 T1010
28234 45915 71111 86325 96913 D6102 J2850 T1012
28288 45990 71120 86327 96920 D6103 J2910 T1013
28312 45999 71130 86329 96921 D6104 J2916 T1014
28313 46020 71250 86331 96922 D6190 J2920 T1015
28322 46030 71260 86332 96999 D6194 J2930 T1016
28340 46040 71270 86334 97001 D6199 J2940 T1017
28341 46045 71275 86335 97002 D6205 J2941 T1018
28345 46050 71550 86336 97003 D6210 J2950 T1019
28450 46060 71551 86337 97004 D6211 J2993 T1020
28455 46070 71552 86340 97005 D6212 J2995 T1021
28456 46080 71555 86341 97006 D6214 J2997 T1022
28465 46083 72010 86343 97010 D6240 J3000 T1023
28470 46200 72020 86344 97012 D6241 J3010 T1024
28475 46220 72040 86352 97014 D6242 J3030 T1025
28476 46221 72050 86353 97016 D6245 J3070 T1026
28485 46230 72052 86355 97018 D6250 J3095 T1027
28510 46250 72069 86356 97022 D6251 J3101 T1028
28515 46255 72070 86357 97024 D6252 J3105 T1029
28525 46257 72072 86359 97026 D6253 J3110 T1030
28600 46258 72074 86360 97028 D6545 J3120 T1031
28605 46260 72080 86361 97032 D6548 J3130 T1502
28606 46261 72090 86367 97033 D6600 J3140 T1503
28615 46262 72100 86376 97034 D6601 J3150 T1505
28630 46270 72110 86378 97035 D6602 J3230 T1999
28635 46275 72114 86382 97036 D6603 J3240 T2001
28636 46280 72120 86384 97039 D6604 J3243 T2002
28645 46285 72125 86386 97110 D6605 J3246 T2003
28660 46288 72126 86403 97112 D6606 J3250 T2004
28665 46320 72127 86406 97113 D6607 J3260 T2005
28666 46500 72128 86430 97116 D6608 J3262 T2007
28675 46600 72129 86431 97124 D6609 J3265 T2010
28705 46604 72130 86480 97139 D6610 J3280 T2011
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
28740 46606 72131 86481 97140 D6611 J3285 T2012
28810 46608 72132 86485 97150 D6612 J3300 T2013
28820 46610 72133 86486 97530 D6613 J3301 T2014
28825 46611 72141 86490 97532 D6614 J3302 T2015
28899 46612 72142 86510 97533 D6615 J3303 T2016
29000 46614 72146 86580 97535 D6624 J3305 T2017
29010 46615 72147 86590 97537 D6634 J3310 T2018
29015 46700 72148 86592 97542 D6710 J3315 T2019
29020 46705 72149 86593 97545 D6720 J3320 T2020
29025 46706 72156 86602 97546 D6721 J3350 T2021
29035 46707 72157 86603 97597 D6722 J3355 T2022
29040 46710 72158 86606 97598 D6740 J3357 T2023
29044 46712 72159 86609 97602 D6750 J3360 T2024
29046 46715 72170 86611 97605 D6751 J3364 T2025
29049 46716 72190 86612 97606 D6752 J3365 T2026
29055 46730 72191 86615 97750 D6780 J3370 T2027
29058 46735 72192 86617 97755 D6781 J3385 T2028
29200 46740 72193 86618 97760 D6782 J3396 T2029
29305 46742 72194 86619 97761 D6783 J3400 T2030
29325 46744 72195 86622 97762 D6790 J3410 T2031
29700 46746 72196 86625 97799 D6791 J3411 T2032
29715 46748 72197 86628 97802 D6792 J3415 T2033
29720 46750 72198 86631 97803 D6793 J3420 T2034
29730 46751 72200 86632 97804 D6794 J3430 T2035
29740 46753 72202 86635 97810 D6920 J3465 T2036
29799 46754 72220 86638 97811 D6930 J3470 T2037
30000 46760 72240 86641 97813 D6940 J3471 T2038
30020 46761 72255 86644 97814 D6950 J3472 T2039
30100 46762 72265 86645 98925 D6975 J3473 T2040
30117 46900 72270 86648 98926 D6980 J3475 T2041
30118 46910 72275 86651 98927 D6985 J3480 T2042
30120 46916 72285 86652 98928 D6999 J3485 T2043
30124 46917 72291 86653 98929 D7111 J3486 T2044
30125 46922 72292 86654 98940 D7140 J3487 T2045
30150 46924 72295 86658 98941 D7210 J3488 T2046
30160 46930 73050 86663 98942 D7220 J3490 T2048
30200 46940 73206 86664 98943 D7230 J3520 T2049
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
30210 46942 73225 86665 98960 D7240 J3530 T2101
30220 46945 73500 86666 98961 D7241 J3535 T4521
30300 46946 73510 86668 98962 D7250 J3570 T4522
30310 46947 73520 86671 98966 D7251 J3590 T4523
30320 46999 73540 86674 98967 D7260 J7030 T4524
30400 47000 73565 86677 98968 D7261 J7040 T4525
30410 47001 74000 86682 98969 D7270 J7042 T4526
30420 47010 74010 86684 99000 D7272 J7050 T4527
30430 47011 74020 86687 99001 D7280 J7060 T4528
30435 47015 74022 86688 99002 D7282 J7070 T4529
30450 47100 74150 86689 99024 D7283 J7100 T4530
30460 47120 74160 86692 99026 D7285 J7110 T4531
30462 47122 74170 86694 99027 D7286 J7120 T4532
30465 47125 74174 86695 99050 D7287 J7131 T4533
30520 47130 74175 86696 99051 D7288 J7178 T4534
30540 47133 74176 86698 99053 D7290 J7180 T4535
30545 47135 74177 86701 99056 D7291 J7183 T4536
30560 47136 74178 86702 99058 D7292 J7185 T4537
30580 47140 74181 86703 99060 D7293 J7186 T4538
30600 47141 74182 86704 99070 D7294 J7187 T4539
30620 47142 74183 86705 99071 D7295 J7189 T4540
30630 47143 74185 86706 99075 D7310 J7190 T4541
30801 47144 74190 86707 99078 D7311 J7191 T4542
30802 47145 74210 86708 99080 D7320 J7192 T4543
30905 47146 74220 86709 99082 D7321 J7193 T5001
30906 47147 74230 86710 99090 D7340 J7194 T5999
30915 47300 74235 86711 99091 D7350 J7195 V2020
30920 47350 74240 86713 99143 D7410 J7196 V2025
30999 47360 74241 86717 99144 D7411 J7197 V2100
31231 47361 74245 86720 99145 D7412 J7198 V2101
31299 47362 74246 86723 99148 D7413 J7199 V2102
31300 47370 74247 86727 99149 D7414 J7300 V2103
31320 47371 74249 86729 99150 D7415 J7302 V2104
31360 47379 74250 86732 99170 D7440 J7303 V2105
31365 47380 74251 86735 99172 D7441 J7304 V2106
31367 47381 74260 86738 99173 D7450 J7306 V2107
31368 47382 74261 86741 99174 D7451 J7307 V2108
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
31370 47399 74262 86744 99175 D7460 J7308 V2109
31375 47400 74263 86747 99183 D7461 J7309 V2110
31380 47420 74270 86750 99190 D7465 J7310 V2111
31382 47425 74280 86753 99191 D7471 J7311 V2112
31390 47460 74283 86756 99192 D7472 J7312 V2113
31395 47480 74290 86757 99195 D7473 J7315 V2114
31400 47490 74291 86759 99199 D7485 J7321 V2115
31420 47500 74300 86762 99201 D7490 J7323 V2118
31500 47505 74301 86765 99202 D7510 J7324 V2121
31502 47510 74305 86768 99203 D7511 J7325 V2199
31505 47530 74320 86771 99204 D7520 J7326 V2200
31510 47550 74327 86774 99205 D7521 J7330 V2201
31511 47552 74328 86777 99211 D7530 J7335 V2202
31512 47553 74329 86778 99212 D7540 J7500 V2203
31513 47554 74330 86780 99213 D7550 J7501 V2204
31515 47555 74340 86784 99214 D7560 J7502 V2205
31520 47556 74355 86787 99215 D7610 J7504 V2206
31525 47560 74360 86788 99217 D7620 J7505 V2207
31526 47561 74363 86789 99218 D7630 J7506 V2208
31527 47562 74400 86790 99219 D7640 J7507 V2209
31528 47563 74410 86793 99220 D7650 J7509 V2210
31529 47564 74415 86800 99221 D7660 J7510 V2211
31530 47570 74420 86803 99222 D7670 J7511 V2212
31531 47600 74425 86804 99223 D7671 J7513 V2213
31535 47605 74430 86805 99224 D7680 J7515 V2214
31536 47610 74440 86806 99225 D7710 J7516 V2215
31540 47612 74445 86807 99226 D7720 J7517 V2218
31541 47620 74450 86808 99231 D7730 J7518 V2219
31560 47630 74455 86812 99232 D7740 J7520 V2220
31561 47700 74470 86813 99233 D7750 J7525 V2221
31570 47701 74475 86816 99234 D7760 J7527 V2299
31571 47711 74480 86817 99235 D7770 J7599 V2300
31575 47712 74485 86821 99236 D7771 J7604 V2301
31576 47715 74710 86822 99238 D7780 J7605 V2302
31577 47720 74740 86825 99239 D7810 J7606 V2303
31578 47721 74742 86826 99241 D7820 J7607 V2304
31579 47740 74775 86828 99242 D7830 J7608 V2305
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
31580 47741 75557 86829 99243 D7840 J7609 V2306
31582 47760 75559 86830 99244 D7850 J7610 V2307
31584 47765 75561 86831 99245 D7852 J7611 V2308
31587 47780 75563 86832 99251 D7854 J7612 V2309
31588 47785 75565 86833 99252 D7856 J7613 V2310
31590 47800 75571 86834 99253 D7858 J7614 V2311
31599 47801 75572 86835 99254 D7860 J7615 V2312
31600 47802 75573 86849 99255 D7865 J7620 V2313
31601 47900 75574 86850 99281 D7870 J7622 V2314
31603 47999 75600 86860 99282 D7871 J7624 V2315
31605 48000 75605 86870 99283 D7872 J7626 V2318
31610 48001 75625 86880 99284 D7873 J7627 V2319
31611 48020 75630 86885 99285 D7874 J7628 V2320
31612 48100 75635 86886 99288 D7875 J7629 V2321
31613 48102 75658 86890 99291 D7876 J7631 V2399
31614 48105 75705 86891 99292 D7877 J7632 V2410
31615 48120 75710 86900 99304 D7880 J7633 V2430
31620 48140 75716 86901 99305 D7899 J7634 V2499
31622 48145 75726 86902 99306 D7910 J7635 V2500
31623 48146 75731 86904 99307 D7911 J7636 V2501
31624 48148 75733 86905 99308 D7912 J7637 V2502
31625 48150 75736 86906 99309 D7920 J7638 V2503
31626 48152 75741 86910 99310 D7921 J7639 V2510
31627 48153 75743 86911 99315 D7940 J7640 V2511
31628 48154 75746 86920 99316 D7941 J7641 V2512
31629 48155 75756 86921 99318 D7943 J7642 V2513
31630 48160 75774 86922 99324 D7944 J7643 V2520
31631 48400 75791 86923 99325 D7945 J7644 V2521
31632 48500 75801 86927 99326 D7946 J7645 V2522
31633 48510 75803 86930 99327 D7947 J7647 V2523
31634 48511 75805 86931 99328 D7948 J7648 V2530
31635 48520 75807 86932 99334 D7949 J7649 V2531
31636 48540 75809 86940 99335 D7950 J7650 V2599
31637 48545 75810 86941 99336 D7951 J7657 V2600
31638 48547 75820 86945 99337 D7952 J7658 V2610
31640 48548 75822 86950 99339 D7953 J7659 V2615
31641 48550 75825 86960 99340 D7955 J7660 V2623
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
31643 48551 75827 86965 99341 D7960 J7665 V2624
31645 48552 75831 86970 99342 D7963 J7667 V2625
31646 48554 75833 86971 99343 D7970 J7668 V2626
31717 48556 75840 86972 99344 D7971 J7669 V2627
31720 48999 75842 86975 99345 D7972 J7670 V2628
31725 49000 75860 86976 99347 D7980 J7674 V2629
31730 49002 75870 86977 99348 D7981 J7676 V2630
31750 49010 75872 86978 99349 D7982 J7680 V2631
31755 49020 75880 86985 99350 D7983 J7681 V2632
31760 49021 75885 86999 99354 D7990 J7682 V2700
31766 49040 75887 87001 99355 D7991 J7683 V2702
31770 49041 75889 87003 99356 D7995 J7684 V2710
31775 49060 75891 87015 99357 D7996 J7685 V2715
31780 49061 75893 87040 99358 D7997 J7686 V2718
31781 49062 75894 87045 99359 D7998 J7699 V2730
31785 49082 75896 87046 99360 D7999 J7799 V2744
31786 49083 75898 87070 99363 D8010 J8498 V2745
31800 49084 75901 87071 99364 D8020 J8499 V2750
31805 49180 75902 87073 99366 D8030 J8501 V2755
31820 49203 75945 87075 99367 D8040 J8510 V2756
31825 49204 75946 87076 99368 D8050 J8515 V2760
31830 49205 75952 87077 99374 D8060 J8520 V2761
31899 49215 75953 87081 99375 D8070 J8521 V2762
32096 49220 75954 87084 99377 D8080 J8530 V2770
32097 49250 75956 87086 99378 D8090 J8540 V2780
32098 49255 75957 87088 99379 D8210 J8560 V2781
32100 49320 75958 87101 99380 D8220 J8562 V2782
32110 49321 75959 87102 99381 D8660 J8565 V2783
32120 49322 75960 87103 99382 D8670 J8597 V2784
32124 49323 75962 87106 99383 D8680 J8600 V2785
32140 49324 75964 87107 99384 D8690 J8610 V2786
32141 49325 75966 87109 99385 D8691 J8650 V2787
32150 49326 75968 87110 99386 D8692 J8700 V2788
32151 49327 75970 87116 99387 D8693 J8705 V2790
32160 49400 75978 87118 99391 D8999 J8999 V2797
32200 49402 75980 87140 99392 D9110 J9000 V2799
32201 49411 75982 87143 99393 D9120 J9002 V5008
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
32310 49412 75984 87147 99394 D9310 J9010 V5010
32320 49418 75989 87149 99395 D9410 J9015 V5011
32400 49419 76000 87150 99396 D9420 J9017 V5014
32405 49421 76001 87152 99397 D9430 J9019 V5020
32440 49422 76010 87153 99401 D9440 J9020 V5030
32442 49423 76080 87158 99402 D9450 J9025 V5040
32445 49424 76098 87164 99403 D9610 J9027 V5050
32480 49425 76100 87166 99404 D9612 J9031 V5060
32482 49426 76101 87168 99406 D9630 J9033 V5070
32484 49427 76102 87169 99407 D9910 J9035 V5080
32486 49428 76120 87172 99408 D9911 J9040 V5090
32488 49429 76125 87176 99409 D9920 J9041 V5095
32501 49435 76140 87177 99411 D9930 J9042 V5100
32503 49436 76376 87181 99412 D9940 J9043 V5110
32504 49440 76377 87184 99420 D9941 J9045 V5120
32505 49441 76380 87185 99429 D9942 J9050 V5130
32506 49442 76390 87186 99441 D9950 J9055 V5140
32507 49446 76496 87187 99442 D9951 J9060 V5150
32540 49450 76497 87188 99443 D9952 J9065 V5160
32550 49451 76498 87190 99444 D9970 J9070 V5170
32552 49452 76499 87197 99450 D9971 J9098 V5180
32553 49460 76506 87205 99455 D9972 J9100 V5190
32560 49465 76514 87206 99456 D9973 J9120 V5200
32561 49568 76516 87207 99460 D9974 J9130 V5210
32562 49580 76536 87209 99461 D9975 J9150 V5220
32601 49582 76604 87210 99462 D9999 J9151 V5230
32604 49585 76645 87220 99463 E0100 J9155 V5240
32606 49587 76700 87230 99464 E0105 J9160 V5241
32607 49600 76705 87250 99465 E0110 J9165 V5242
32608 49605 76770 87252 99466 E0111 J9171 V5243
32609 49606 76775 87253 99467 E0112 J9175 V5244
32653 49610 76776 87254 99468 E0113 J9178 V5245
32658 49611 76800 87255 99469 E0114 J9179 V5246
32659 49900 76801 87260 99471 E0116 J9181 V5247
32661 49904 76802 87265 99472 E0117 J9185 V5248
32662 49905 76805 87267 99475 E0118 J9190 V5249
32663 49906 76810 87269 99476 E0130 J9200 V5250
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
32665 49999 76811 87270 99477 E0135 J9201 V5251
32666 50020 76812 87271 99478 E0140 J9202 V5252
32667 50021 76813 87272 99479 E0141 J9206 V5253
32668 50250 76814 87273 99480 E0143 J9207 V5254
32669 50290 76815 87274 99485 E0144 J9208 V5255
32670 50300 76816 87275 99486 E0147 J9209 V5256
32671 50323 76817 87276 99487 E0148 J9211 V5257
32672 50325 76818 87277 99488 E0149 J9212 V5258
32673 50327 76819 87278 99489 E0153 J9213 V5259
32674 50328 76820 87279 99495 E0154 J9214 V5260
32701 50329 76821 87280 99496 E0155 J9215 V5261
32800 50360 76825 87281 99499 E0156 J9216 V5262
32810 50370 76826 87283 99500 E0157 J9217 V5263
32815 50380 76827 87285 99501 E0158 J9218 V5264
32820 50500 76828 87290 99502 E0159 J9219 V5265
32850 50520 76830 87299 99503 E0160 J9225 V5266
32851 50525 76831 87300 99504 E0161 J9226 V5267
32852 50526 76856 87301 99505 E0162 J9228 V5268
32853 50540 76857 87305 99506 E0163 J9230 V5269
32854 50562 76870 87320 99507 E0165 J9245 V5270
32855 50660 76872 87324 99509 E0167 J9250 V5271
32856 50686 76873 87327 99510 E0168 J9260 V5272
32900 50688 76881 87328 99511 E0170 J9261 V5273
32905 50690 76882 87329 99512 E0171 J9263 V5274
32906 50722 76885 87332 99600 E0172 J9264 V5275
32940 50725 76886 87335 99601 E0175 J9265 V5281
32960 50727 76930 87336 99602 E0181 J9266 V5282
32997 50728 76932 87337 99605 E0182 J9268 V5283
32998 50770 76936 87338 99606 E0184 J9270 V5284
32999 50810 76937 87339 99607 E0185 J9280 V5285
33010 50825 76940 87340 A0021 E0186 J9293 V5286
33011 50830 76941 87341 A0080 E0187 J9300 V5287
33015 50845 76942 87350 A0090 E0188 J9302 V5288
33020 50920 76945 87380 A0100 E0189 J9303 V5289
33025 50930 76946 87385 A0110 E0190 J9305 V5290
33030 51020 76948 87389 A0120 E0193 J9307 V5298
33031 51030 76950 87390 A0130 E0194 J9310 V5299
Proprietary information of UnitedHealthcare Community Plan. Copyright 2013 United HealthCare Services, Inc. 2013R0060B
2013A UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT
33050 51040 76965 87391 A0140 E0196 J9315 V5336
33120 51045 76970 87400 A0160 E0197 J9320 V5362
33130 51050 76975 87420 A0170 E0198 J9328 V5363
33140 51060 76977 87425 A0180 E0199 J9330 V5364
33141 76998 87427
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