Medicare Advantage

Medical Policy

Notification

Bundled Procedure Codes

Notification Issued Date:

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.

Policy Attachment

Attachment to Policy #

MA00.026y

Attachment:

Policy #:

MA00.026y

Description:

Procedures/Services Not Eligible for Separate Reimbursement when reported with another specific Procedure/Service

Title:

Bundled Procedure Codes

The procedure/service identified in Column A is not eligible for separate reimbursement consideration when reported in conjunction with procedure/service(s) identified in Column B.

Column A	Column B
Interpretation and report only of an EKG is not eligible for separate reimbursement consideration when reported with select E/M services.
93010	99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99281, 99282, 99283, 99284, 99285
93042	99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99281, 99282, 99283, 99284, 99285

Removal of impacted cerumen is not eligible for separate reimbursement consideration when reported with audiologic function testing.
G0268	92550, 92551, 92552, 92553, 92555, 92556, 92557, 92558, 92562, 92563, 92565, 92567, 92568, 92570, 92571, 92572, 92575, 92576, 92577, 92579, 92582, 92583, 92584, 92587, 92588, 92596

Ultrasonic guidance for needle placement is not eligible for separate reimbursement consideration when reported with certain tendon, ligament, aponeurosis (e.g., plantar "fascia") or trigger point injections.
76942	20550, 20551, 20552, 20553

Laparoscopic surgical paraesophageal/esophageal hernia repair is not eligible for separate reimbursement consideration when reported with bariatric surgical procedures.
43281	43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888
43282	43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888
43283	43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888
43332	43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888
43333	43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888

Version Effective Date:

1/1/2026

Version Issued Date:

1/9/2026

Version Reissued Date: