code pair edits do not bypass with any modifier · code pair edits do not bypass with any modifier...
TRANSCRIPT
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 1 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 0506T 92002 NCCI Policy Manual
Integral/Incident To 0506T 92004 NCCI Policy Manual
Integral/Incident To 0506T 92012 NCCI Policy Manual
Integral/Incident To 0506T 92014 NCCI Policy Manual
Integral/Incident To 12041 59400 NCCI Policy Manual 2018
Chapter VII G-5 12041 59409 NCCI Policy Manual 2018
Chapter VII G-5 12041 59410 NCCI Policy Manual 2018
Chapter VII G-5 14000 19301 NCCI Policy Manual
Integral/Incident To 14000 19302 NCCI Policy Manual
Integral/Incident To 14000 19303 NCCI Policy Manual
Integral/Incident To 14000 19304 NCCI Policy Manual
Integral/Incident To 14000 19305 NCCI Policy Manual
Integral/Incident To 14000 19306 NCCI Policy Manual
Integral/Incident To 14000 19307 NCCI Policy Manual
Integral/Incident To 14000 19316 NCCI Policy Manual
Integral/Incident To 14000 19318 NCCI Policy Manual
Integral/Incident To 14001 19301 NCCI Policy Manual
Integral/Incident To 14001 19302 NCCI Policy Manual
Integral/Incident To 14001 19303 NCCI Policy Manual
Integral/Incident To 14001 19304 NCCI Policy Manual
Integral/Incident To 14001 19305 NCCI Policy Manual
Integral/Incident To 14001 19306 NCCI Policy Manual
Integral/Incident To
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 2 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 14001 19307 NCCI Policy Manual
Integral/Incident To 14001 19316 NCCI Policy Manual
Integral/Incident To 14001 19318 NCCI Policy Manual
Integral/Incident To 14301 19301 NCCI Policy Manual
Integral/Incident To 14301 19302 NCCI Policy Manual
Integral/Incident To 14301 19303 NCCI Policy Manual
Integral/Incident To 14301 19304 NCCI Policy Manual
Integral/Incident To 14301 19305 NCCI Policy Manual
Integral/Incident To 14301 19306 NCCI Policy Manual
Integral/Incident To 14301 19307 NCCI Policy Manual
Integral/Incident To 14301 19316 NCCI Policy Manual
Integral/Incident To 14301 19318 NCCI Policy Manual
Integral/Incident To 14301 19364 NCCI Policy Manual
Integral/Incident To 14301 S2066 NCCI Policy Manual
Integral/Incident To 14301 S2067 NCCI Policy Manual
Integral/Incident To 14301 S2068 NCCI Policy Manual
Incident To Service 14302 19301 NCCI Policy Manual
Incident To Service 14302 19302 NCCI Policy Manual
Incident To Service 14302 19303 NCCI Policy Manual
Integral/Incident To 14302 19304 NCCI Policy Manual
Integral/Incident To 14302 19305 NCCI Policy Manual
Integral/Incident To 14302 19306 NCCI Policy Manual
Integral/Incident To
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 3 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 14302 19307 NCCI Policy Manual
Integral/Incident To 14302 19316 NCCI Policy Manual
Integral/Incident To 14302 19318 NCCI Policy Manual
Integral/Incident To 15734 19364 NCCI Policy Manual
Integral/Incident To 15734 S2066 NCCI Policy Manual
Incident To Service 15734 S2067 NCCI Policy Manual
Incident To Service 15734 S2068 NCCI Policy Manual
Incident To Service 15823 67901 NCCI Policy Manual 2018
Chapter VIII D 15823 67904 NCCI Policy Manual 2018
Chapter VIII D 19342 19316 NCCI Policy Manual
Integral/Incident To 19370 11970 NCCI Policy Manual 2018
Chapter I B 20912 21335 NCCI Policy Manual
Integral/Incident To 20926 19364 NCCI Policy Manual
Incident To Service 20926 S2066 NCCI Policy Manual
Integral/Incident To 20926 S2067 NCCI Policy Manual
Incident To Service 20926 S2068 NCCI Policy Manual
Incident To Service 22214 22612 NCCI Policy Manual
Integral/Incident To 22214 22630 NCCI Policy Manual
Integral/Incident To 22214 22633 NCCI Policy Manual
Integral/Incident To 22325 22612 NCCI Policy Manual
Integral/Incident To 22325 22630 NCCI Policy Manual
Integral/Incident To 22325 22633 NCCI Policy Manual
Integral/Incident To
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 4 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 22830 22551 NCCI Policy Manual 2018
Chapter IV I 10 22830 22554 NCCI Policy Manual 2018
Chapter IV I 10 22830 22845 NCCI Policy Manual 2018
Chapter IV I 10 22830 22846 NCCI Policy Manual 2018
Chapter IV I 10 22830 22849 NCCI Policy Manual 2018
Chapter IV I 10 22845 22855 NCCI Policy Manual
Incident To Service 22850 22840 NCCI Policy Manual
Incident To Service 22850 22842 NCCI Policy Manual
Incident To Service 22852 22840 NCCI Policy Manual
Incident To Service 22852 63047 NCCI Policy Manual
Incident To Service 27006 29914 NCCI Policy Manual
Incident To Service 27006 29915 NCCI Policy Manual
Incident To Service 27006 29916 NCCI Policy Manual
Incident To Service 27036 29914 NCCI Policy Manual
Incident To Service 27036 29915 NCCI Policy Manual
Incident To Service 27036 29916 NCCI Policy Manual
Incident To Service 27062 29914 NCCI Policy Manual
Incident To Service 27062 29915 NCCI Policy Manual
Incident To Service 27062 29916 NCCI Policy Manual
Incident To Service 27071 29914 NCCI Policy Manual
Incident To Service 27071 29915 NCCI Policy Manual
Incident To Service 27071 29916 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 5 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 27187 29914 NCCI Policy Manual
Incident To Service 27187 29915 NCCI Policy Manual
Incident To Service 27187 29916 NCCI Policy Manual
Incident To Service 27305 29914 NCCI Policy Manual
Incident To Service 27305 29915 NCCI Policy Manual
Incident To Service 27305 29916 NCCI Policy Manual
Incident To Service 29807 23455 NCCI Policy Manual 2018
Chapter IV E 29807 29806 NCCI Policy Manual 2018
Chapter IV E 29819 29806 NCCI Policy Manual 2018
Chapter IV E 29822 23120 NCCI Policy Manual 2018
Chapter IV E 29822 23130 NCCI Policy Manual 2018
Chapter IV E 29822 23410 NCCI Policy Manual 2018
Chapter IV E 29822 23412 NCCI Policy Manual 2018
Chapter IV E 29822 23430 NCCI Policy Manual 2018
Chapter IV E 29822 23455 NCCI Policy Manual 2018
Chapter IV E 29822 23670 NCCI Policy Manual 2018
Chapter IV E 29822 29824 NCCI Policy Manual 2018
Chapter IV E 29822 29827 NCCI Policy Manual 2018
Chapter IV E 29822 29828 NCCI Policy Manual 2018
Chapter IV E 29823 23130 NCCI Policy Manual 2018
Chapter IV E 29823 23410 NCCI Policy Manual 2018
Chapter IV E 29823 29806 NCCI Policy Manual 2018
Chapter IV E
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 6 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 29823 29824 NCCI Policy Manual 2018
Chapter IV E 29823 29827 NCCI Policy Manual 2018
Chapter IV E 29826 23410 NCCI Policy Manual 2018
Chapter IV E 29826 23412 NCCI Policy Manual 2018
Chapter IV E 29861 29914 NCCI Policy Manual
Incident To Service 29861 29915 NCCI Policy Manual
Incident To Service 29861 29916 NCCI Policy Manual
Incident To Service 29862 29914 NCCI Policy Manual
Incident To Service 29862 29915 NCCI Policy Manual
Incident To Service 29862 29916 NCCI Policy Manual
Incident To Service 29863 29914 NCCI Policy Manual
Incident To Service 29863 29915 NCCI Policy Manual
Incident To Service 29863 29916 NCCI Policy Manual
Incident To Service 29875 29879 NCCI Policy Manual 2018
Chapter I J 29875 29880 NCCI Policy Manual 2018
Chapter I J 29875 29881 NCCI Policy Manual 2018
Chapter I J 29875 29888 NCCI Policy Manual 2018
Chapter I J 29876 29880 NCCI Policy Manual
Incident To Service 29881 27446 NCCI Policy Manual
Incident To Service 29888 27429 NCCI Policy Manual
Incident To Service 29999 29861 NCCI Policy Manual
Incident To Service 29999 29862 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 7 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 29999 29863 NCCI Policy Manual
Incident To Service 29999 29914 NCCI Policy Manual
Incident To Service 29999 29915 NCCI Policy Manual
Incident To Service 29999 29916 NCCI Policy Manual
Incident To Service 31295 31233 NCCI Policy Manual
Incident To Service 31295 31237 NCCI Policy Manual
Incident To Service 31295 31238 NCCI Policy Manual
Incident To Service 31295 31241 NCCI Policy Manual
Incident To Service 31295 31256 NCCI Policy Manual
Incident To Service 31267 31295 NCCI Policy Manual
Incident To Service 31296 31233 NCCI Policy Manual
Incident To Service 31296 31235 NCCI Policy Manual
Incident To Service 31296 31237 NCCI Policy Manual
Incident To Service 31296 31238 NCCI Policy Manual
Incident To Service 31296 31241 NCCI Policy Manual
Incident To Service 31253 31296 NCCI Policy Manual
Incident To Service 31296 31256 NCCI Policy Manual
Incident To Service 31296 31267 NCCI Policy Manual
Incident To Service 31276 31296 NCCI Policy Manual
Incident To Service 31297 31233 NCCI Policy Manual
Incident To Service 31297 31235 NCCI Policy Manual
Incident To Service 31297 31237 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 8 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 31297 31238 NCCI Policy Manual
Incident To Service 31297 31241 NCCI Policy Manual
Incident To Service 31297 31256 NCCI Policy Manual
Incident To Service 31257 31297 NCCI Policy Manual
Incident To Service 31259 31297 NCCI Policy Manual
Incident To Service 31297 31267 NCCI Policy Manual
Incident To Service 31287 31297 NCCI Policy Manual
Incident To Service 31288 31297 NCCI Policy Manual
Incident To Service 31296 31297 NCCI Policy Manual
Incident To Service 31298 31233 NCCI Policy Manual
Incident To Service 31298 31235 NCCI Policy Manual
Incident To Service 31298 31237 NCCI Policy Manual
Incident To Service 31298 31238 NCCI Policy Manual
Incident To Service 31253 31298 NCCI Policy Manual
Incident To Service 31257 31298 NCCI Policy Manual
Incident To Service 31259 31298 NCCI Policy Manual
Incident To Service 31276 31298 NCCI Policy Manual
Incident To Service 31287 31298 NCCI Policy Manual
Incident To Service 31288 31298 NCCI Policy Manual
Incident To Service 31298 31296 NCCI Policy Manual
Incident To Service 31298 31297 NCCI Policy Manual
Incident To Service 33241 33249 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 9 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 35761 19364 NCCI Policy Manual
Incident To Service 35761 S2066 NCCI Policy Manual
Incident To Service 35761 S2067 NCCI Policy Manual
Incident To Service 35761 S2068 NCCI Policy Manual
Incident To Service 43235 43289 NCCI Policy Manual
Incident To Service 43235 43644 NCCI Policy Manual
Incident To Service 43235 43770 NCCI Policy Manual
Incident To Service 43235 43775 NCCI Policy Manual
Incident To Service 43235 43848 NCCI Policy Manual
Incident To Service 43281 43279 NCCI Policy Manual
Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43281 43644 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43281 43645 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43281 43770 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43281 43771 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43281 43772 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 10 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 43281 43773 NCCI Policy Manual
Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43281 43774 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43281 43775 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43281 43843 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43279 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43644 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43645 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43770 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43771 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43772 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43773 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 11 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 43282 43774 NCCI Policy Manual
Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43775 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43282 43843 NCCI Policy Manual Incident To Service Regence Reimbursement Policy SUR 104 - Hiatal Hernia
43327 43335 NCCI Policy Manual Incident To Service
43774 43644 NCCI Policy Manual Incident To Service
43774 43645 NCCI Policy Manual Incident To Service
43774 43770 NCCI Policy Manual Incident To Service
43774 43771 NCCI Policy Manual Incident To Service
43774 43773 NCCI Policy Manual Incident To Service
43774 43775 NCCI Policy Manual Incident To Service
52352 52356 NCCI Policy Manual Integral/Incident To
55520 49505 NCCI Policy Manual Incident To Service
55520 49507 NCCI Policy Manual Incident To Service
55530 49505 NCCI Policy Manual Incident To Service
55530 49507 NCCI Policy Manual Incident To Service
55530 49520 NCCI Policy Manual Incident To Service
55550 49505 CPT Assistant August 2002
55550 49507 CPT Assistant August 2002
55550 49520 CPT Assistant August 2002
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 12 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 59051 59025 NCCI Policy Manual
Incident To Service 59514 59510 CPT Assistant
August 2002 59515 59510 CPT Text/Definition 59620 59618 NCCI Policy Manual 2018
Chapter I H 59622 59618 NCCI Policy Manual
Incident To Service 70480 70450 NCCI Policy Manual
Incident To Service 73221 73222 NCCI Policy Manual
Incident To Service 74300 47562 NCCI Policy Manual
Incident To Service 74300 47564 NCCI Policy Manual
Incident To Service 74300 47600 NCCI Policy Manual
Incident To Service 74301 47562 NCCI Policy Manual
Incident To Service 74301 47564 NCCI Policy Manual
Incident To Service 74301 47600 NCCI Policy Manual
Incident To Service 76000 29914 NCCI Policy Manual
Incident To Service 76000 29915 NCCI Policy Manual
Incident To Service 76000 29916 NCCI Policy Manual
Incident To Service 76001 29914 NCCI Policy Manual
Incident To Service 76001 29915 NCCI Policy Manual
Incident To Service 76001 29916 NCCI Policy Manual
Incident To Service 87635 U0003 NCCI Policy Manual
Incident To Service 93975 76870 NCCI Policy Manual
Incident To Service 93976 76870 NCCI Policy Manual
Incident To Service 96160 99201 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 13 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 96160 99202 NCCI Policy Manual
Incident To Service 96160 99203 NCCI Policy Manual
Incident To Service 96160 99204 NCCI Policy Manual
Incident To Service 96160 99205 NCCI Policy Manual
Incident To Service 96160 99211 NCCI Policy Manual
Incident To Service 96160 99212 NCCI Policy Manual
Incident To Service 96160 99213 NCCI Policy Manual
Incident To Service 96160 99214 NCCI Policy Manual
Incident To Service 96160 99215 NCCI Policy Manual
Incident To Service 96160 99381 NCCI Policy Manual
Incident To Service 96160 99382 NCCI Policy Manual
Incident To Service 96160 99383 NCCI Policy Manual
Incident To Service 96160 99384 NCCI Policy Manual
Incident To Service 96160 99385 NCCI Policy Manual
Incident To Service 96160 99386 NCCI Policy Manual
Incident To Service 96160 99387 NCCI Policy Manual
Incident To Service 96160 99391 NCCI Policy Manual
Incident To Service 96160 99392 NCCI Policy Manual
Incident To Service 96160 99393 NCCI Policy Manual
Incident To Service 96160 99394 NCCI Policy Manual
Incident To Service 96160 99395 NCCI Policy Manual
Incident To Service 96160 99396 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 14 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 96160 99397 NCCI Policy Manual
Incident To Service 96127 99381 NCCI Policy Manual
Incident To Service 96127 99382 NCCI Policy Manual
Incident To Service 96127 99383 NCCI Policy Manual
Incident To Service 96127 99384 NCCI Policy Manual
Incident To Service 96127 99385 NCCI Policy Manual
Incident To Service 96127 99386 NCCI Policy Manual
Incident To Service 96127 99387 NCCI Policy Manual
Incident To Service 96127 99391 NCCI Policy Manual
Incident To Service 96127 99392 NCCI Policy Manual
Incident To Service 96127 99393 NCCI Policy Manual
Incident To Service 96127 99394 NCCI Policy Manual
Incident To Service 96127 99395 NCCI Policy Manual
Incident To Service 96127 99396 NCCI Policy Manual
Incident To Service 96127 99397 NCCI Policy Manual
Incident To Service 99172 99381 NCCI Policy Manual
Incident To Service 99172 99382 NCCI Policy Manual
Incident To Service 99172 99383 NCCI Policy Manual
Incident To Service 99172 99384 NCCI Policy Manual
Incident To Service 99172 99385 NCCI Policy Manual
Incident To Service 99172 99386 NCCI Policy Manual
Incident To Service 99172 99387 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 15 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 99172 99391 NCCI Policy Manual
Incident To Service 99172 99392 NCCI Policy Manual
Incident To Service 99172 99393 NCCI Policy Manual
Incident To Service 99172 99394 NCCI Policy Manual
Incident To Service 99172 99395 NCCI Policy Manual
Incident To Service 99172 99396 NCCI Policy Manual
Incident To Service 99172 99397 NCCI Policy Manual
Incident To Service 99173 92002 NCCI Policy Manual
Incident To Service 99173 92004 NCCI Policy Manual
Incident To Service 99173 92012 NCCI Policy Manual
Incident To Service 99173 92014 NCCI Policy Manual
Incident To Service 99173 99201 NCCI Policy Manual
Incident To Service 99173 99202 NCCI Policy Manual
Incident To Service 99173 99203 NCCI Policy Manual
Incident To Service 99173 99204 NCCI Policy Manual
Incident To Service 99173 99205 NCCI Policy Manual
Incident To Service 99173 99211 NCCI Policy Manual
Incident To Service 99173 99212 NCCI Policy Manual
Incident To Service 99173 99213 NCCI Policy Manual
Incident To Service 99173 99214 NCCI Policy Manual
Incident To Service 99173 99215 NCCI Policy Manual
Incident To Service 99173 99381 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 16 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 99173 99382 NCCI Policy Manual
Incident To Service 99173 99383 NCCI Policy Manual
Incident To Service 99173 99384 NCCI Policy Manual
Incident To Service 99173 99385 NCCI Policy Manual
Incident To Service 99173 99386 NCCI Policy Manual
Incident To Service 99173 99387 NCCI Policy Manual
Incident To Service 99173 99391 NCCI Policy Manual
Incident To Service 99173 99392 NCCI Policy Manual
Incident To Service 99173 99393 NCCI Policy Manual
Incident To Service 99173 99394 NCCI Policy Manual
Incident To Service 99173 99395 NCCI Policy Manual
Incident To Service 99173 99396 NCCI Policy Manual
Incident To Service 99173 99397 NCCI Policy Manual
Incident To Service 99174 99201 NCCI Policy Manual
Incident To Service 99174 99202 NCCI Policy Manual
Incident To Service 99174 99203 NCCI Policy Manual
Incident To Service 99174 99204 NCCI Policy Manual
Incident To Service 99174 99205 NCCI Policy Manual
Incident To Service 99174 99211 NCCI Policy Manual
Incident To Service 99174 99212 NCCI Policy Manual
Incident To Service 99174 99213 NCCI Policy Manual
Incident To Service 99174 99214 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 17 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 99174 99215 NCCI Policy Manual
Incident To Service 99174 99381 NCCI Policy Manual
Incident To Service 99174 99382 NCCI Policy Manual
Incident To Service 99174 99383 NCCI Policy Manual
Incident To Service 99174 99384 NCCI Policy Manual
Incident To Service 99174 99385 NCCI Policy Manual
Incident To Service 99174 99386 NCCI Policy Manual
Incident To Service 99174 99387 NCCI Policy Manual
Incident To Service 99174 99391 NCCI Policy Manual
Incident To Service 99174 99392 NCCI Policy Manual
Incident To Service 99174 99393 NCCI Policy Manual
Incident To Service 99174 99394 NCCI Policy Manual
Incident To Service 99174 99395 NCCI Policy Manual
Incident To Service 99174 99396 NCCI Policy Manual
Incident To Service 99174 99397 NCCI Policy Manual
Incident To Service 99177 92002 NCCI Policy Manual
Incident To Service 99177 92004 NCCI Policy Manual
Incident To Service 99177 92012 NCCI Policy Manual
Incident To Service 99177 92014 NCCI Policy Manual
Incident To Service 99177 99201 NCCI Policy Manual
Incident To Service 99177 99202 NCCI Policy Manual
Incident To Service 99177 99203 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 18 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 99177 99204 NCCI Policy Manual
Incident To Service 99177 99205 NCCI Policy Manual
Incident To Service 99177 99211 NCCI Policy Manual
Incident To Service 99177 99212 NCCI Policy Manual
Incident To Service 99177 99213 NCCI Policy Manual
Incident To Service 99177 99214 NCCI Policy Manual
Incident To Service 99177 99215 NCCI Policy Manual
Incident To Service 99177 99381 NCCI Policy Manual
Incident To Service 99177 99382 NCCI Policy Manual
Incident To Service 99177 99383 NCCI Policy Manual
Incident To Service 99177 99384 NCCI Policy Manual
Incident To Service 99177 99385 NCCI Policy Manual
Incident To Service 99177 99386 NCCI Policy Manual
Incident To Service 99177 99387 NCCI Policy Manual
Incident To Service 99177 99391 NCCI Policy Manual
Incident To Service 99177 99392 NCCI Policy Manual
Incident To Service 99177 99393 NCCI Policy Manual
Incident To Service 99177 99394 NCCI Policy Manual
Incident To Service 99177 99395 NCCI Policy Manual
Incident To Service 99177 99396 NCCI Policy Manual
Incident To Service 99177 99397 NCCI Policy Manual
Incident To Service 99201 G0101 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 19 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE 99202 G0101 NCCI Policy Manual
Incident To Service 99203 G0101 NCCI Policy Manual
Incident To Service 99204 G0101 NCCI Policy Manual
Incident To Service 99205 G0101 NCCI Policy Manual
Incident To Service 99211 G0101 NCCI Policy Manual
Incident To Service 99212 G0101 NCCI Policy Manual
Incident To Service 99213 G0101 NCCI Policy Manual
Incident To Service 99214 G0101 NCCI Policy Manual
Incident To Service 99215 G0101 NCCI Policy Manual
Incident To Service A4281 E0603 NCCI Policy Manual
Incident To Service A4282 E0603 NCCI Policy Manual
Incident To Service A4283 E0603 NCCI Policy Manual
Incident To Service A4284 E0603 NCCI Policy Manual
Incident To Service A4285 E0603 NCCI Policy Manual
Incident To Service A4286 E0603 NCCI Policy Manual
Incident To Service E0650 E0651 Reimbursement Policy Adm 134
- Pneumatic Compression Device
E0650 E0652 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0651 E0652 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0655 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0655 E0652 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0655 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 20 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE E0655 E0676 Reimbursement Policy Adm 134
- Pneumatic Compression Device
E0656 E0650 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0656 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0656 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0656 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0657 E0650 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0657 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0657 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0657 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0660 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0660 E0652 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0660 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0660 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0665 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0665 E0652 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0665 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0665 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 21 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE E0666 E0651 Reimbursement Policy Adm 134
- Pneumatic Compression Device
E0666 E0652 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0666 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0666 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0667 E0650 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0667 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0668 E0650 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0668 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0669 E0650 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0669 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0670 E0650 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0670 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0670 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0671 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0671 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0671 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0672 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 22 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE E0672 E0675 Reimbursement Policy Adm 134
- Pneumatic Compression Device
E0672 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0673 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0673 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0673 E0676 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0676 E0650 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0676 E0651 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0676 E0652 Reimbursement Policy Adm 134 - Pneumatic Compression Device
E0676 E0675 Reimbursement Policy Adm 134 - Pneumatic Compression Device
G0101 99384 NCCI Policy Manual Incident To Service
G0101 99385 NCCI Policy Manual Incident To Service
G0101 99386 NCCI Policy Manual Incident To Service
G0101 99387 NCCI Policy Manual Incident To Service
G0101 99394 NCCI Policy Manual Incident To Service
G0101 99395 NCCI Policy Manual Incident To Service
G0101 99396 NCCI Policy Manual Incident To Service
G0101 99397 NCCI Policy Manual Incident To Service
G0101 S0610 NCCI Policy Manual Incident To Service
G0101 S0612 NCCI Policy Manual Incident To Service
G0102 99384 NCCI Policy Manual Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 23 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE G0102 99385 NCCI Policy Manual
Incident To Service G0102 99386 NCCI Policy Manual
Incident To Service G0102 99387 NCCI Policy Manual
Incident To Service G0102 99394 NCCI Policy Manual
Incident To Service G0102 99395 NCCI Policy Manual
Incident To Service G0102 99396 NCCI Policy Manual
Incident To Service G0102 99397 NCCI Policy Manual
Incident To Service G0453 95940 NCCI Policy Manual
Incident To Service G0453 95941 NCCI Policy Manual
Incident To Service S0610 99201 NCCI Policy Manual
Incident To Service S0610 99202 NCCI Policy Manual
Incident To Service S0610 99203 NCCI Policy Manual
Incident To Service S0610 99204 NCCI Policy Manual
Incident To Service S0610 99205 NCCI Policy Manual
Incident To Service S0610 99211 NCCI Policy Manual
Incident To Service S0610 99212 NCCI Policy Manual
Incident To Service S0610 99213 NCCI Policy Manual
Incident To Service S0610 99214 NCCI Policy Manual
Incident To Service S0610 99215 NCCI Policy Manual
Incident To Service S0610 99384 NCCI Policy Manual
Incident To Service S0610 99385 NCCI Policy Manual
Incident To Service S0610 99386 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 24 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE S0610 99387 NCCI Policy Manual
Incident To Service S0610 99394 NCCI Policy Manual
Incident To Service S0610 99395 NCCI Policy Manual
Incident To Service S0610 99396 NCCI Policy Manual
Incident To Service S0610 99397 NCCI Policy Manual
Incident To Service S0612 99201 NCCI Policy Manual
Incident To Service S0612 99202 NCCI Policy Manual
Incident To Service S0612 99203 NCCI Policy Manual
Incident To Service S0612 99204 NCCI Policy Manual
Incident To Service S0612 99205 NCCI Policy Manual
Incident To Service S0612 99211 NCCI Policy Manual
Incident To Service S0612 99212 NCCI Policy Manual
Incident To Service S0612 99213 NCCI Policy Manual
Incident To Service S0612 99214 NCCI Policy Manual
Incident To Service S0612 99215 NCCI Policy Manual
Incident To Service S0612 99384 NCCI Policy Manual
Incident To Service S0612 99385 NCCI Policy Manual
Incident To Service S0612 99386 NCCI Policy Manual
Incident To Service S0612 99387 NCCI Policy Manual
Incident To Service S0612 99394 NCCI Policy Manual
Incident To Service S0612 99395 NCCI Policy Manual
Incident To Service S0612 99396 NCCI Policy Manual
Incident To Service
Code Pair Edits Do Not Bypass with any Modifier Our health plan has determined that the following code pairs are typically not appropriately reported
together, therefore, modifiers will NOT bypass the denial on the following code pairs:
7/1/2020 Page 25 of 25 Supplement to CCI version 26.2
CPT® is a trademark of the American Medical Association The appearance of HCPCS/CPT codes does not necessarily indicate coverage.
DENY SUPPORT RATIONALE S0612 99397 NCCI Policy Manual
Incident To Service U0001 87635 NCCI Policy Manual
Incident To Service U0001 U0002 NCCI Policy Manual
Incident To Service U0002 87635 NCCI Policy Manual
Incident To Service U0002 U0004 NCCI Policy Manual
Incident To Service