IBC Medical Policies

The Centers for Medicare and Medicaid Services (CMS) Medicare Coverage Database (MCD) contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), local articles, and proposed NCD decisions. The database also includes several other types of National Coverage policy related documents, including National Coverage Analyses (NCAs), Coding Analyses for Labs (CALs), Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) proceedings, Technical Assessments (TAs), and Medicare coverage guidance documents.

The MCD is located at https://www.cms.gov/medicare-coverage-database , one of the top links on the CMS website homepage.

Name	ID	MPDispTitle	MPPolicyCategory	MPPolicyNumber	MPPolicyNumberwithoutversion	MPPolicyPageName	MPTitle	Title	MPattachmentdataPub
85257D39006E7945852584BE00618356	29	Always Bundled Procedure Codes	Administrative (00)	MA00.026g	MA00.026	85257D39006E7945852584BE00618356	Always Bundled Procedure Codes	Always Bundled Procedure Codes	{"1776":{"Id":1776,"MPAttachmentLetter":"A","Title":"CPT Codes and HCPCS Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852584BE0061835A"},}
85257D39006E7945852582BA004934E6	34	Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus	Administrative (00)	MA00.037h	MA00.037	85257D39006E7945852582BA004934E6	Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus	Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus	{"1784":{"Id":1784,"MPAttachmentLetter":"A","Title":"CPT/HCPCS Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852582BA004934EC"},}
B62FA99106A1AEC1852581E9006281CE	18	Cast and Splint Applications and Associated Supplies Provided in the Office Setting	Administrative (00)	MA00.012b	MA00.012	B62FA99106A1AEC1852581E9006281CE	Cast and Splint Applications and Associated Supplies Provided in the Office Setting	Cast and Splint Applications and Associated Supplies Provided in the Office Setting	{"1681":{"Id":1681,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"A2DFF3878C4FCBD3852581E9006281DF"},}
8DFCA2ECFC6B5415852582DC00509E93	40	Consultation Services		MA00.049	MA00.049	8DFCA2ECFC6B5415852582DC00509E93	Consultation Services	Consultation Services
85257D39006E79458525851B005C2382	65	Contrast Agents Used in Conjunction with Echocardiography	Radiology (09)	MA09.004b	MA09.004	85257D39006E79458525851B005C2382	Contrast Agents Used in Conjunction with Echocardiography	Contrast Agents Used in Conjunction with Echocardiography
85257D39006E7945852584FD00658A7A	38	Criteria for Reimbursement of Emergency Room Services	Administrative (00)	MA00.044b	MA00.044	85257D39006E7945852584FD00658A7A	Criteria for Reimbursement of Emergency Room Services	Criteria for Reimbursement of Emergency Room Services
85257D39006E794585258360004DFC78	62	Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum	DME (05)	MA05.028d	MA05.028	85257D39006E794585258360004DFC78	Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum	Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
BC141503B9A36679852583740052BE4A	36	Facility Reporting of Observation Services	Administrative (00)	MA00.040a	MA00.040	BC141503B9A36679852583740052BE4A	Facility Reporting of Observation Services	Facility Reporting of Observation Services
85257D39006E79458525841D004AA188	66	High Osmolar Contrast Agents	Radiology (09)	MA09.005a	MA09.005	85257D39006E79458525841D004AA188	High Osmolar Contrast Agents	High Osmolar Contrast Agents
85257D39006E79458525843B0044336B	39	Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)	Administrative (00)	MA00.045d	MA00.045	85257D39006E79458525843B0044336B	Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)	Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
85257D39006E79458525847100594308	27	Inpatient Hospital Readmission	Administrative (00)	MA00.023a	MA00.023	85257D39006E79458525847100594308	Inpatient Hospital Readmission	Inpatient Hospital Readmission
85257D39006E794585258514005A66E5	64	Instrument-Based Vision Screening	Medicine (07)	MA07.048a	MA07.048	85257D39006E794585258514005A66E5	Instrument-Based Vision Screening	Instrument-Based Vision Screening
85257D39006E79458525847100593A59	26	Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances	Administrative (00)	MA00.022	MA00.022	85257D39006E79458525847100593A59	Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances	Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
85257D39006E79458525841E0056253E	67	Low Osmolar Contrast Agents	Radiology (09)	MA09.008a	MA09.008	85257D39006E79458525841E0056253E	Low Osmolar Contrast Agents	Low Osmolar Contrast Agents
85257D39006E79458525841E00562B1A	69	Magnetic Resonance Imaging (MRI) Contrast Agents	Radiology (09)	MA09.010b	MA09.010	85257D39006E79458525841E00562B1A	Magnetic Resonance Imaging (MRI) Contrast Agents	Magnetic Resonance Imaging (MRI) Contrast Agents
85257D39006E79458525840000486245	55	Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period	Clinical Logic (03)	MA03.009d	MA03.009	85257D39006E79458525840000486245	Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period	Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
85257D39006E7945852584D6004E86B3	49	Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service	Clinical Logic (03)	MA03.003g	MA03.003	85257D39006E7945852584D6004E86B3	Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service	Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service	{"1781":{"Id":1781,"MPAttachmentLetter":"A","Title":"E&M codes appended with modifier 25 should be reimbursed at 50 percent of the applicable fee schedule amount when submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure.","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852584D6004E86CB"},"1782":{"Id":1782,"MPAttachmentLetter":"B","Title":"Problem-focused E&M codes appended with modifier 25 should be reimbursed at 50 percent of the applicable fee schedule amount when submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preven","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852584D6004E86DC"},}
85257D39006E7945852585960050D150	48	Modifier 50: Bilateral Procedure	Clinical Logic (03)	MA03.002e	MA03.002	85257D39006E7945852585960050D150	Modifier 50: Bilateral Procedure	Modifier 50: Bilateral Procedure
85257D39006E7945852583F900649418	59	Modifier 52 Reduced Services	Clinical Logic (03)	MA03.014a	MA03.014	85257D39006E7945852583F900649418	Modifier 52 Reduced Services	Modifier 52 Reduced Services
85257D39006E7945852583CF0048AD21	61	Modifier 53 Discontinued Procedure		MA03.018a	MA03.018	85257D39006E7945852583CF0048AD21	Modifier 53 Discontinued Procedure	Modifier 53 Discontinued Procedure
85257D39006E7945852583F90064A3CF	56	Modifier 57 Decision for Surgery	Clinical Logic (03)	MA03.010d	MA03.010	85257D39006E7945852583F90064A3CF	Modifier 57 Decision for Surgery	Modifier 57 Decision for Surgery
85257D39006E7945852585960050DA8A	17	Modifier 62: Two Surgeons	Administrative (00)	MA00.011f	MA00.011	85257D39006E7945852585960050DA8A	Modifier 62: Two Surgeons	Modifier 62: Two Surgeons
85257D39006E7945852585960050C9EB	20	Modifier 66: Surgical Team		MA00.014e	MA00.014	85257D39006E7945852585960050C9EB	Modifier 66: Surgical Team	Modifier 66: Surgical Team	{"1856":{"Id":1856,"MPAttachmentLetter":"A","Title":"Team Surgery Review Form","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852585960050C9F2"},"1857":{"Id":1857,"MPAttachmentLetter":"B","Title":"Eligible Indicators 1 and 2 Procedure Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852585960050C9FA"},}
85257D39006E7945852584790052FFAE	47	Modifier 76: Repeat Procedure or Service by Same Physican or Qualified Health Professional		ma03.001a	ma03.001	85257D39006E7945852584790052FFAE	Modifier 76: Repeat Procedure or Service by Same Physican or Qualified Health Professional	Modifier 76: Repeat Procedure or Service by Same Physican or Qualified Health Professional
85257D39006E79458525847E0061CB14	53	Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional		MA03.007a	MA03.007	85257D39006E79458525847E0061CB14	Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional	Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional
85257D39006E79458525848F0042DBA7	54	Modifier 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period	Clinical Logic (03)	MA03.008b	MA03.008	85257D39006E79458525848F0042DBA7	Modifier 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period	Modifier 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
85257D39006E79458525848F0042E3A5	58	Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period	Clinical Logic (03)	MA03.012c	MA03.012	85257D39006E79458525848F0042E3A5	Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period	Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
85257D39006E79458525854B00567D32	57	Modifiers 26 (Professional Component) and TC (Technical Component)	Clinical Logic (03)	MA03.011e	MA03.011	85257D39006E79458525854B00567D32	Modifiers 26 (Professional Component) and TC (Technical Component)	Modifiers 26 (Professional Component) and TC (Technical Component)
85257D39006E79458525848F0042EE64	60	Modifiers for Shared or Split Surgical Services (Modifiers 54, 55, 56)	Clinical Logic (03)	MA03.017b	MA03.017	85257D39006E79458525848F0042EE64	Modifiers for Shared or Split Surgical Services (Modifiers 54, 55, 56)	Modifiers for Shared or Split Surgical Services (Modifiers 54, 55, 56)
85257D39006E794585258489006077DA	52	Modifiers XE, XS, XP, XU, and 59	Clinical Logic (03)	MA03.005b	MA03.005	85257D39006E794585258489006077DA	Modifiers XE, XS, XP, XU, and 59	Modifiers XE, XS, XP, XU, and 59
093d0248-79b2-46c9-bbcd-d945d71d6e34	87	ModifiersforAssistant-at-SurgeryServices:80,81,82,andASMA00.015g	Administrative (00)	MA00.015g	MA00.015	093d0248-79b2-46c9-bbcd-d945d71d6e34	Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS	Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
85257D39006E79458525848900607139	43	Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services	Anesthesia (01)	MA01.005d	MA01.005	85257D39006E79458525848900607139	Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services	Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services	{"1766":{"Id":1766,"MPAttachmentLetter":"A","Title":"Multiple Reduction Diagnostic Services","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525848900607170"},}
A5AD9538B36B0D9A85258466004509F0	41	Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services		MA00.050	MA00.050	A5AD9538B36B0D9A85258466004509F0	Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services	Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services	{"1713":{"Id":1713,"MPAttachmentLetter":"A","Title":"Multiple Reduction Always Therapy Procedure Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"E08B4F6D7B0E162785258466004509FB"},}
8B06FE21A3E2306B8525853B006E4424	70	Multiple Surgery Payment Reduction	Surgery (11)	MA11.032f	MA11.032	8B06FE21A3E2306B8525853B006E4424	Multiple Surgery Payment Reduction	Multiple Surgery Payment Reduction	{"1790":{"Id":1790,"MPAttachmentLetter":"B","Title":"HCPCS Codes To Which Multiple Surgery Payment Reduction Applies","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"A280D3FC17E8523E8525853B006E4430"},"1791":{"Id":1791,"MPAttachmentLetter":"A2","Title":"CPT Codes To Which Multiple Surgery Payment Reduction Applies","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"02D44CD5CEC9DE558525853B006E4441"},"1792":{"Id":1792,"MPAttachmentLetter":"A1","Title":"CPT Codes To Which Multiple Surgery Payment Reduction Applies","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"54C6A14C5BD5FFDE8525853B006E445F"},}
85257D39006E79458525841D004A822C	37	National Correct Coding Initiative (NCCI) Code Pair Edits	Administrative (00)	MA00.041	MA00.041	85257D39006E79458525841D004A822C	National Correct Coding Initiative (NCCI) Code Pair Edits	National Correct Coding Initiative (NCCI) Code Pair Edits
4A9E6A730665DE088525856C007555A7	76	PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services	Administrative (00)	MA00.010z	MA00.010	4A9E6A730665DE088525856C007555A7	PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services	PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services	{"1807":{"Id":1807,"MPAttachmentLetter":"A1","Title":"DME Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"C9E7B42FACFFDAD88525856C007555B5"},"1808":{"Id":1808,"MPAttachmentLetter":"A2","Title":"DME Network Rules and Limited Circumstances cont'd.","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"1CF7BA47D2890E028525856C007555C5"},"1809":{"Id":1809,"MPAttachmentLetter":"A3","Title":"DME Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"0E50650DDCFAB1D98525856C007555CE"},"1810":{"Id":1810,"MPAttachmentLetter":"B1","Title":"Laboratory Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"624A8282E1C55A848525856C007555D6"},"1811":{"Id":1811,"MPAttachmentLetter":"B2","Title":"Laboratory Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"A34766299D1E505D8525856C007555E1"},"1812":{"Id":1812,"MPAttachmentLetter":"B3","Title":"Laboratory Network Rules and Limited Circumstances cont'd.","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"4D7AC97A31EAB9C08525856C007555EA"},"1813":{"Id":1813,"MPAttachmentLetter":"C1","Title":"Radiology Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"0CF09ECE4B1A6E098525856C007555F2"},"1814":{"Id":1814,"MPAttachmentLetter":"C2","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"FFF32834F8657B178525856C007555FA"},"1815":{"Id":1815,"MPAttachmentLetter":"D","Title":"Physical Medicine & Rehabilitation Network Rules and Limited Circumstances","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"80378E0E69E228118525856C00755602"},}
85257D39006E794585258489006085D0	24	Radiologic Guidance of a Procedure	Administrative (00)	MA00.019f	MA00.019	85257D39006E794585258489006085D0	Radiologic Guidance of a Procedure	Radiologic Guidance of a Procedure	{"1777":{"Id":1777,"MPAttachmentLetter":"A","Title":"Radiologic Guidance and Supervision and Interpretation Procedure Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E794585258489006085D7"},}
67705FDEC08C535F852585880062ACA2	45	Reimbursement for Components of Comprehensive Laboratory Panels		MA01.006a	MA01.006	67705FDEC08C535F852585880062ACA2	Reimbursement for Components of Comprehensive Laboratory Panels	Reimbursement for Components of Comprehensive Laboratory Panels	{"1827":{"Id":1827,"MPAttachmentLetter":"A","Title":"CPT Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"EEF7B1B6F23D48E8852585880062ACAF"},}
85257D39006E79458525847100594AEC	68	Reimbursement for Radiopharmaceutical Agents for Professional Providers	Radiology (09)	MA09.009j	MA09.009	85257D39006E79458525847100594AEC	Reimbursement for Radiopharmaceutical Agents for Professional Providers	Reimbursement for Radiopharmaceutical Agents for Professional Providers
85257D39006E794585257DE00073FD8C	63	Reimbursement for the Administration of Immunizations	Medicine (07)	MA07.019a	MA07.019	85257D39006E794585257DE00073FD8C	Reimbursement for the Administration of Immunizations	Reimbursement for the Administration of Immunizations
db8a020d-5eaa-4fb5-ac6a-f1d73a33414c	86	ReimbursementforanIntraocularLensMA11.043a	Surgery (11)	MA11.043a	MA11.043	db8a020d-5eaa-4fb5-ac6a-f1d73a33414c	Reimbursement for an Intraocular Lens	Reimbursement for an Intraocular Lens
0E615B4A9F37B7F28525855100613D7B	75	Reporting and Documentation Requirements for Anesthesia Services		MA00.009g	MA00.009	0E615B4A9F37B7F28525855100613D7B	Reporting and Documentation Requirements for Anesthesia Services	Reporting and Documentation Requirements for Anesthesia Services
85257D39006E7945852582F000467D68	28	Reporting Requirements for Drugs and Biologics	Administrative (00)	MA00.024b	MA00.024	85257D39006E7945852582F000467D68	Reporting Requirements for Drugs and Biologics	Reporting Requirements for Drugs and Biologics
85257D39006E79458525846B006CB7EC	74	Use of a Robotic-Assisted Surgical System		ma11.057a	ma11.057	85257D39006E79458525846B006CB7EC	Use of a Robotic-Assisted Surgical System	Use of a Robotic-Assisted Surgical System
DBB10BFAEBC9F3C385258275004FF8A6	31	X-rays Associated with Fractures in the Office Setting	Administrative (00)	MA00.031d	MA00.031	DBB10BFAEBC9F3C385258275004FF8A6	X-rays Associated with Fractures in the Office Setting	X-rays Associated with Fractures in the Office Setting	{"1683":{"Id":1683,"MPAttachmentLetter":"A","Title":"Codes eligible for reimbursement when billed by Hand Surgeons, Orthopedic Surgeons, or Sports Medicine Specialists","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"16177F583FC4A41685258275004FF972"},"1684":{"Id":1684,"MPAttachmentLetter":"B","Title":"Codes eligible for reimbursement when billed by Podiatrists","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"614E1F051BE33B0085258275004FFA3C"},}

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Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.