Horizon Blue Cross Blue Shield of NJ
Bundling Rules
1/1/16
A
B
Code
Code
70486
70450
70487
70460
70488
70470
70490
70450
70491
70460
70492
70470
70490
70486
70491
70487
70492
70488
70490
71250
70491
71260
70492
71270
Rule
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
70490
70486
Formula Used for Reimbursement
When all three are billed together
100% of the highest RVU , 50% of the
second and 25% of the third
When all three are billed together
100% of the procedure with the highest
RVU , 50% of the second and 25% of the
third
When all three are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
70450
70491
70487
70460
70492
70488
70470
74176
71250
74177
71260
74178
71270
74176
70490
74177
70491
74178
70492
74176
74177
74178
71250
70490
71260
70490
71270
70490
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
Code
74176
74177
74178
74176
74177
74178
70490
70491
70492
70490
70491
70492
70490
70491
70492
70490
70491
70492
70490
70491
70492
70490
70491
70492
Code
71250
70491
71260
70491
71270
70491
Rule
Formula Used for Reimbursement
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
70492
71260
70492
71270
70492
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
72192
71260
72192
71270
72192
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
72193
71260
72193
71270
72193
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
72194
71260
72194
71270
72194
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
74150
71260
74150
71270
74150
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
74160
71260
74160
71270
74160
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
74170
71260
74170
71270
74170
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
72128
72131
72129
72132
72130
72133
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
Code
70450
70460
70470
70450
70460
70470
70450
70460
70470
Code
71250
70490
71260
70490
71270
70490
Rule
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
70491
71260
70491
71270
70491
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
71250
70492
71260
70492
71270
70492
100% of the procedure with the highest
When a code from column A is billed with a
RVU, 50% of the second and 25% of the
pair of codes from column B
third
70540
70547
70542
70548
70543
70549
70551
70540
70552
70542
70553
70543
70551
70544
70552
70545
70553
70546
70551
70547
70552
70548
70553
70549
71250
72192
71260
72193
71270
72194
71250
74150
71260
74160
71270
74170
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
72141
72146
When all three are billed together
100% of the procdedure with the highest
RVU, 50% of the second and 25% of the
third
When all three are billed together
100% of the procdedure with the highest
RVU, 50% of the second and 25% of the
third
72148
72142
72147
72149
Formula Used for Reimbursement
Code
Code
Rule
72156
72157
When any combination is billed together
72158
72141
72146
72142
72147
72156
72157
72146
72148
72147
72149
72157
72158
72148
72141
72149
72142
72158
72156
72195
74181
72196
74182
72197
74183
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 50% of the second
72156
72158
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
72147
72158
72142
72147
72158
72147
72141
72156
72158
72146
72158
72157
72142
72158
72157
72141
72158
72142
72146
72158
72146
72141
Formula Used for Reimbursement
100% of the procdedure with the highest
RVU, 50% of the second and 25% of the
third
Code
Code
Rule
72156
72157
When column A codes are billed together
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
72149
72157
72142
72149
72157
72149
72141
72156
72149
72147
72149
72147
72141
72156
72149
72146
72142
72149
72146
72149
72146
72141
72156
72157
72148
72157
72142
72148
72157
72141
72148
72156
72147
72148
72142
72147
72148
Formula Used for Reimbursement
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
Code
Code
Rule
72147
72141
When column A codes are billed together
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When column A codes are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
72148
72156
72146
72148
72142
72146
72148
73218
73221
73219
73222
73220
73223
73718
73721
73719
73722
73720
73723
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 75% of the second
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 75% of the second
72197
72198
Formula Used for Reimbursement
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When all three are billed together
100% of 72198, 50% of 73725, 0% of
72197
When any combination is billed together
100% of the procedure with the highest
RVU, 50% of the second and 50% of the
third
73725
72198
74185
73725
70544
70547
70545
70548
70546
70549
70544
70545
70546
70544
70545
70546
70544
70545
70546
When a code from column A is billed with a 100% of the procedure with the highest
code from column B
RVU, 75% of the second
70547
70551
70547
70552
70547
70553
When a column A code is billed with a pair 100% of the procedure with the highest
RVU, 75% of the second and 50% of third
of codes from column B
70548
70551
70548
70552
70548
70553
When a code from column A is billed with a 100% of the procedure with the highest
pair of codes from column B
RVU, 75% of the second and 50% of third
70549
70551
70549
70552
70549
70553
When a code from column A is billed with a 100% of the procedure with the highest
pair of codes from column B
RVU, 75% of the second and 50% of third
Code
Code
Rule
Formula Used for Reimbursement
70496
70498
71275
73206
100% of the procedure with the highest
When any combination of column A codes RVU, 50% of the second and 25% of the
are billed
third or more
74175
70496
70498
71275
73206
100% of the procedure with the highest
When any combination of column A codes RVU, 50% of the second and 25% of the
are billed
third or more
75635
70496
70498
71275
73206
100% of the procedure with the highest
When any combination of column A codes RVU, 50% of the second and 25% of the
are billed
third or more
73706
70496
70498
71275
73206
100% of the procedure with the highest
When any combination of column A codes RVU, 50% of the second and 25% of the
are billed
third or more
74174
70496
70498
71275
73206
100% of the procedure with the highest
When any combination of column A codes RVU, 50% of the second and 25% of the
are billed
third or more
72191
78802
78803
78306
78320
78315
78320
78306
78315
When billed together
100% of the procedure with the highest
RVU, 50% of the second
When billed together
100% of the procedure with the highest
RVU, 50% of the second
When billed together
100% of the procedure with the highest
RVU, 50% of the second
When billed together
100% of the procedure with the highest
RVU, 50% of the second
76816
76817
76819
76820
100% of the procedure with the highest
When any combination of column A codes RVU, 50% of the second and 25% of the
are billed
third or more
76821
76816
76817
76818
76820
76821
100% of the procedure with the highest
When any combination of column A codes RVU, 50% of the second and 25% of the
are billed
third or more
Code
Code
Rule
Formula Used for Reimbursement
76770
76830
76705
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed
third or more
76857
76805
76820
76819
76805
76820
76818
76805
76817
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed
third
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed
third
When billed together
100% of the procedure with the highest
RVU, 50% of the second
76700
76775
76830
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed
third or more
76856
76830
76856
76705
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed
third or more
76775
76770
76830
76705
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed
third or more
76856
76770
76830
76705
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed
third or more
76857
76705
76700
76770
When three or more of the codes from
column A are billed
100% of 76700, 50% of 76775, 0% for
76705, 0% for 76770
When all three are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
76775
76825
76805
76817
76700
76857
76830
76801
76817
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed
third
When any combination of column A codes 100% of the procedure with the highest
are billed
RVU, 50% of the second
Code
76820
Code
76811
76815
Rule
100% of the procedure with the highest
RVU, 50% of the second
When all three are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When all three are billed together
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
76820
76821
76805
76820
76821
Formula Used for Reimbursement
When the column A code is billed with a
code from column B
76811
76816
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed together
third or more
76820
76821
76825
76821
100% of the procedure with the highest
When any combination of column A codes
RVU, 50% of the second and 25% of the
are billed together
third
76825
76827
76820
76815
76818
76815
76819
76816
76819
76816
76818
When the column A code is billed with a
pair of codes in column B
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
76821
76816
76818
76816
76819
When the column A code is billed with a
pair of codes in column B
100% of the procedure with the highest
RVU, 50% of the second and 25% of the
third
When the column A code is billed with a
code from column B
100% of the procedure with the highest
RVU, 50% of the second highest
When billed together
100% of the highest RVU, 50% of the
second highest
When billed together
100% of the highest RVU, 50% of the
second highest
When billed together
100% of the highest RVU, 50% of the
second highest
When billed together
100% of the highest RVU, 50% of the
second highest
76805
76821
76811
76812
76816
76825
76827
76825
76828
76826
76828
76827
76826
76831
76376
76377
When a code from column A is billed with a 100% of the highest RVU, 50% of the
code from column B
second highest
Code
Code
Rule
Formula Used for Reimbursement
76816
76817
When any combination of column A codes 100% of the highest RVU, 50% of the
are billed together
second and 25% of the third or more
76819
76826
76828
76811
When any combination of column A codes 100% of the highest RVU, 50% of the
are billed
second and 25% of the third
76817
76820
76816
When any combination of column A codes 100% of the highest RVU, 50% of the
are billed together
second and 25% of the third
76828
76818
76817
76813
76817
76815
When billed together
100% of the highest RVU, 50% of the
second
When billed together
100% of the highest RVU, 50% of the
second
PET / MRI
70540
73218**
78812
71550
74181
72195
73718**
**bilateral eligible
100% for the PET exam, 50% for the MRI
When the code from column A is billed with
with the highest RVU and 25% for any
one or more codes from column B
additional MRIs with lessor RVUs