UHC Medicare denying 76881 as inclusive with E/M

[Biller2023]

We billed 99215 with 25 modifier + 76881 with RT modifier for Dx M25.561 (pain in right knee) and M17.11 (unilateral primary osteoarthritis, right knee). UHC Medicare paid for 99215 and denied 76881. 76881 was denied stating "charge is not reimbursable as a separate charge, payment is included in allowance for another procedure). This code is included in Current Procedural Terminology (CPT) 99215; this means it can't be separately reimbursed. Of note,the interpretation of a radiology service (whether reported globally or with modifier 26) is included in the Evaluation and Management (E/M)service. This is applicable only when the E/M and radiology services are performed by the Same Individual Physician or Other QHP on thesame date of service for the same patient, as these services usually aren’t distinct from the E/M service when both are rendered on the sameday. To be considered for additional reimbursement, a provider must submit a separate written radiology interpretation report for a radiologyservice appended with modifier 26 or reported globally. This means the billed code and modifier can't be verified"
Please let us know how to fix this issue.

 

[sls314]

We billed 99215 with 25 modifier + 76881 with RT modifier for Dx M25.561 (pain in right knee) and M17.11 (unilateral primary osteoarthritis, right knee). UHC Medicare paid for 99215 and denied 76881. 76881 was denied stating "charge is not reimbursable as a separate charge, payment is included in allowance for another procedure). This code is included in Current Procedural Terminology (CPT) 99215; this means it can't be separately reimbursed. Of note,the interpretation of a radiology service (whether reported globally or with modifier 26) is included in the Evaluation and Management (E/M)service. This is applicable only when the E/M and radiology services are performed by the Same Individual Physician or Other QHP on thesame date of service for the same patient, as these services usually aren’t distinct from the E/M service when both are rendered on the sameday. To be considered for additional reimbursement, a provider must submit a separate written radiology interpretation report for a radiologyservice appended with modifier 26 or reported globally. This means the billed code and modifier can't be verified"
Please let us know how to fix this issue.

The message you posted tells you the next step: You need to send in a copy of the full interpretation and report to receive reimbursement for the ultrasound.


Under UHC's Professional/Technical Component Policy, if the provider simply reviews the ultrasound findings as part of the E/M service and does not generate a separate written interpretation and report, the professional component is considered included in the E/M service and is not separately reimbursable.

If the provider owns the ultrasound equipment, reimbursement for the technical component would generally still be available. (My understanding is that you'd have to bill for the TC only, if the professional portion was bundled into the E/M and there was no separate report.)

However, separate reimbursement for the professional component requires documentation of a full written interpretation and report. Without that report, UHC considers the physician's review of the study to be part of the E/M service rather than a separately payable radiology interpretation.

Here's the link to the Commercial Reimbursement Policy Bulletin. I also pasted the relevant portion below. https://www.uhcprovider.com/content...ursement/rpub/UHC-COMM-RPUB-February-2026.pdf





Note that it applies for Medicare Advantage as well.

Here's the link to the same language on the Medicare Advantage Reimbursement Policy Update Bulletin: https://www.uhcprovider.com/content...imbursement/rpub/UHC-MEDADV-RPUB-FEB-2026.pdf

It was implemented for Medicaid in most states too, although it was rolled out at different times for different states. https://www.uhcprovider.com/content...imbursement-update-bulletin-february-2026.pdf