Commercial

Medical Policy

Title:

Bundled Procedure Codes

Policy #:

00.01.52ac

Policy

The intent of this policy is to communicate procedures or services that are not eligible for reimbursement or not eligible for separate reimbursement consideration by the Company, when billed alone or in conjunction with other services, as outlined in this policy.

Attachments A, B, and C apply to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, and

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tient facility providers billing on a UB-04 claim form or the electronic equivalent, 837i.

Attachment D applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p.

The procedure codes listed in Attachment A are considered "always bundled" and "bundled" services, based on the Medicare Physician Fee Schedule Database (MPFSD) Status B and T Indicators, respectively. Status B procedure codes are considered always bundled into the reimbursement for other services and, therefore, are not eligible for separate reimbursement, whether billed alone or in conjunction with other services. Status T procedure codes are considered bundled into the reimbursement for other services reported by the same provider, for the same member, on the same date and, therefore, are not eligible for separate reimbursement. Participating providers may not bill members for these services.

The procedure codes listed in Attachment B may be covered by the Company; however, they are not eligible for separate reimbursement consideration, whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.

The procedure codes listed in Attachment C may be covered by the Company; however, they are not eligible for reimbursement consideration. Participating providers may not bill members for these services.

The procedure codes listed in Attachment D may be covered by the Company; however, they are not eligible for separate reimbursement consideration when reported in conjunction with other services identified in this attachment, by the same provider, for the same member, on the same date. Participating providers may not bill members for these services.

Guidelines

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

When determining services listed in this policy, the Company takes into consideration the Medicare Physician Fee Schedule Database (MPFSD), the American Medical Association Current Procedure Technology (CPT) Manual, Centers for Medicare & Medicaid Services (CMS) guidelines, Company policies, and other appropriate sources, when determining services listed in this policy.

The MPFSD identifies procedure codes with status B and T indicators. The status B indicator is used when the reimbursement for certain procedure codes is always considered bundled into the reimbursement for other services. The Status T indicator is used when the reimbursement for certain procedure codes is bundled into the reimbursement for other services reimbursed to the same provider, for the same member, on the same date of service.

References

Centers for Medicare & Medicaid Services (CMS). National Physician Fee Schedule Relative Value File. [CMS Web site]. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. Accessed June 15, 2026.

Centers for Medicare & Medicaid Services Medicare Claims Processing Manual. Chapter 23 - Fee Schedule Administration and Coding. Requirements. Table of Contents. (Rev. 4188, 12-28-18). Available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. Accessed June 15, 2026.

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)

Please see Attachments A, B, C, and D.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Attachment A: Always Bundled Procedures and Services (Status B); Bundled Procedures and Services (Status T)

Attachment B: Procedures and Services Not Eligible for Separate Reimbursement

Attachment C: Procedures and Services Not Eligible for Reimbursement

Attachment D: Procedures and Services Not Eligible for Separate Reimbursement When Reported With Another Specific Procedure or Service

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 00.01.52ac:

10/01/2026

This version of the policy will become effective 10/01/2026.

This policy has been updated to communicate the Company's revised reimbursement position that a pelvic exam performed during an Evaluation and Management (E/M) service, represented by CPT 99459, is not eligible for separate reimbursement.

CPT 99459 has been added to Attachment B of the policy.

The following HCPCS codes have been terminated and removed from Attachment C of the policy: G2061, G2062, G2063, G9037, G9038, Q0239.

Revisions From 00.01.52ab:

7/01/2026

This policy has been identified for the CPT/HCPCS quarterly code update effective 7/01/2026.

The following HCPCS codes were added to Attachment C of the policy: G0574, G0575, G0669, G0670, G0671, G0672, G0673, G0674, G0675, G0676, G0677, G0678.

Revisions From 00.01.52aa:

4/01/2026

This policy has been identified for the CPT/HCPCS quarterly code update effective 4/01/2026.

HCPCS code G2211 in Attachment B of the policy has undergone a code narrative revision.

Revisions From 00.01.52z:

1/01/2026

This policy has been identified and updated for the CPT/HCPCS code update effective 1/01/2026.

Procedure code 77417 has been added to Attachment A of this policy.

The following CPT codes have been removed from Attachment A of this policy:

92921, 92925, 92929, 92934, 92938, 92944

The following CPT/HCPCS codes have been added to Attachment B of this policy:

90482, 90483, 90484, 97007, 97008, 97009, 99445, 99470, G0570, G0660, G0661, G0662, G0663, G0664, G0665, G0666, G0667, G0668

The following CPT codes have been removed from Attachment B of this policy:

0662T and 0663T.

Procedure code G0136 has undergone a narrative revision.

Procedure code G0071 has been removed from Attachment C of this policy.

The following CPT/HCPCS codes in Attachment C of this policy have undergone narrative revisions:

99453, 99454, 99457, G2076, G2077

Revisions From 00.01.52y:

12/31/2025

This version of the policy will become effective 12/31/2025. This policy is being updated to communicate the Company's reimbursement position for procedure codes identified by the Medicare Physician Fee Schedule (MPFS) status indicator T as bundled services and certain procedure codes that are not eligible for separate reimbursement consideration when reported with another specific procedure or service by the same provider, for the same member, on the same date.

Revisions From 00.01.52x:

1/01/2025

This policy has been identified and updated for the CPT/HCPCS code update effective 1/01/2025.

The following CPT codes have been added to Attachment A of this policy:

38225, 38226, and 38227

The following CPT codes have been removed from Attachment A of this policy:

0537T, 0538T, and 0539T

The following CPT codes have had narratives revised on Attachment A of this policy:

98960, 98961, and 98962

The following HCPCS code have been added to Attachment B of this policy:

G0537, G0538, G0539, G0540, G0541, G0542, G0543, G0544, G0545, G0556, G0557, G0558, and G0559

The following CPT/HCPCS code have been added to Attachment C of this policy:

98016, G0532, G0533, G0534, G0535, G0536, G0546, G0547, G0548, G0549, G0550, G0551, and Q0521

Revisions From 00.01.52w:

10/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2024.

HCPCS codes 96202 and 96203 have moved from attachment A to attachment B of this policy:

The following HCPCS codes have been added to Attachment C of this policy:

Q0516, Q0517, Q0518, Q0519, Q0520

Revisions From 00.01.52v:

07/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2024.

HCPCS code A9506 has been added to attachment B of this policy.

The following CPT/HCPCS codes have been added to attachment C of this policy:

G0519, G0520, G0521, G0522, G0523, G0524, G0525, G0526, G0527, G0528, G0529, G0530, G0531, G9037, and G9038

____________________________________________________________________

The following procedure codes have been removed from attachment B of this policy:

99492, 99493, 99494, G2214, 99459

Revisions From 00.01.52u:

01/02/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2024 .

The following HCPCS/CPT codes have been added to Att B of this policy:

G0019, G0022, G0023, G0024, G0136, G0140, G0146, G2211, 97550, 97551, 97552, and 99459

The following procedure codes have been removed from Att A and added to Att B because CMS has removed the code's Indicator Status B:

G2211

Revisions From 00.01.52t:

10/23/2023

This version of the policy will become effective 10/23/2023. The intent of this policy remains unchanged, but has been updated to communicate the reimbursement position of cognitive geriatric assessment services represented by procedure code 99483.

The reimbursement position of procedure code 99483 has been revised from Not Eligible for Reimbursement to Eligible.

Procedure code 99483 has been removed from the policy.

Revisions From 00.01.52s:

07/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 7/01/2023.

The following procedure codes have been removed from Att B to Att A of the policy because they have been added to CMS Indicator Status B:

96202 and 96203

_____________________________________________________________________

The following procedure codes were removed from the policy:

Q0243 and Q0245

Revisions From 00.01.52r:

01/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2023.

The following procedure codes have been added to the policy:

15853, 15854, 96202, 96203, and G0323

The following procedure codes have had narrative revisions:

99242, 99243, 99244, 99245, 99252, 99253, 99254, 99255, 99417, 99446, 99447, 99448, 99449, 99451, 99483, and G2212

The following procedure codes have been removed from the policy:

15850, 99241, 99251, 99339, and 99340

Revisions From 00.01.52q:

10/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2022.

The following procedure codes have had narrative revisions: Q9001, Q9002, and Q9003

Revisions From 00.01.52p:

04/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2022.

The procedure code H2038 has been added to the policy.

Revisions From 00.01.52o:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2022.

The following CPT/HCPCS codes have been added to the policy:
99424, 99425, 99426, 99427, 99437, 99241, 99242, 99243, 99244, 99245, 99251,
99252, 99253, 99254, 99255, G2168, and G2169

The following CPT/HCPCS codes have been removed from this policy:
91300, 91301, 91302, 91303, G2064, and G2065

HCPCS code G1013 has had a narrative revision.

Revisions From 00.01.52n:

10/11/2021

This version of the policy will become effective 10/11/2021. The intent of this policy remains unchanged, but has been updated to communicate the the addition and removal of procedure codes from the policy.

CPT code 96040 has been deleted from Attachment A of this policy.

CPT Code 96904 has been added to Attachment B of this policy to communicate the Company's continued reimbrusement position. This reimbursement position was previously communicated in policy:

07.07.05b: Photography, including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy.

Revisions From 00.01.52m:

07/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2021.

The following procedure code was added to Attachment B of the policy:

0662T and 0663T

Revisions From 00.01.52l:

04/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2021.

The following procedure code was added to Attachment A of the policy:

G2211

The following procedure codes were added to Attachment C of the policy:

91302, 91303, G2020, G2172, Q0245

Revisions From 00.01.52k:

01/18/2021

This version of the policy will become effective 01/18/2021. This has been updated to communicate the reimbursement position of all services not eligible for reimbursement or not eligible for separate reimbursement by the Company. Attachment B: Procedures/Services Not Eligible for Separate Reimbursement and Attachment C: Procedures/Services Not Eligible for Reimbursement, have been introduced to this policy to represent services that are not eligible for separate reimbursement or not eligible for reimbursement and were previously communicated in other policies.

The following criteria have been added to the policy:

The procedure codes listed in Attachment B may be covered by the Company; however, are not eligible for separate reimbursement consideration whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.

The following CPT code has been added to this policy in attachment B and is not eligible for separate reimbursement. This position was previously communicated in other policies:

92285

Additional:
This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021.

Procedure code 96040 has been added to Attachment A of this policy.

The following Procedure codes have been added to Attachment B of this policy:
G2212, G2214, 99417 99439, and 99490

Procedure code G2058 termed and was removed from Attachment B of this policy

Procedure code 99072 was moved from Attachment B to Attachment A of this policy

Procedure code 99490 in Attachment B of this policy had a narrative revision.

The following procedure codes have been added to Attachment C of this policy:

91300, 91301, G2215, G2216, Q0239, and Q0243

Revisions From 00.01.52j:

10/01/2020

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2020

The following procedure code has been added to the policy:
36000

Revisions From 00.01.52i:

01/01/2020

This version of the policy will become effective 01/01/2020. Effective 01/01/2020, the following three Healthcare Common Procedure Coding System (HCPCS) codes will be included in the Always Bundled Procedure Codes policy. They are not eligible for separate reimbursement.

99360
G0175
S0220
S0221

CPT code 99360 previously resided in the policy entitled Physician Standby Services (00.10.16d). The other three codes previously resided in the policy entitled Medical Team Conferences (00.10.31c).

Revisions From 00.01.52h:

07/01/2019

This version of the policy will become effective 07/01/2019.

Effective 07/01/2019, Healthcare Common Procedure Coding System (HCPCS) code S8030 will be removed from the Proton Beam Therapy Radiation policy. It is not eligible for separate reimbursement. As such, it will be included in the Always Bundled Procedure Codes policy.

S8030 Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy

Revisions From 00.01.52g:

01/01/2019

This version of the policy will become effective 01/01/2019.

The following CPT codes has been deleted from this policy: 99090

The following CPT codes have been added to this policy: 0537T, 0538T, 0539T

Revisions From 00.01.52f:

11/26/2018

This version of the policy will become effective 11/26/2018.

This policy has been updated as a result of the quarterly update to the Medicare Physician Fee Schedule.

The following Procedure codes have been added to Attachment A of the policy: 34839, G0501

The following Procedure codes have been deleted from Attachment A of the policy: 99091, 99487, 99488, 99489

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

10/1/2026

Version Issued Date: