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Policy Attachment

MA00.026w
B
MA00.026w
Procedures/Services Not Eligible for Separate Reimbursement
Always Bundled Procedure Codes




Procedures and Services Not Eligible for Separate Reimbursement


This list is not all-inclusive and may not include procedures/services that have been identified as not eligible for separate reimbursement in more specific policies. Additions and deletions will be made as changes occur or the reimbursement position of a procedure/service changes.



​Procedure Code​​
0662T
​0663T
​15853
​15854
92285
​96202
​96203
​96904
​97550
​97551
​97552
99174
99177
99360
​99417
​​99424
​99425
​99426
​99427
​99437
99439
99484
99490
99491
A9506
​G0019
​G0022
​G0023
​G0024
​G0140
​G0146
G0175
​G0323
G0506
G0537
G0538
G0539
G0540
G0541
G0542
G0543
G0544
G0545
G0556
G0557
G0558
G0559



01/01/2025
02/25/2025
N/A
Claim Payment Policy Bulletin
Medicare Advantage
b8057771-0f7d-4c4f-9e51-9bbd0cf78521
Yes