Will be Added Code Pair Edits Do Not Bypass with Modifier
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS and XU. Proper use of modifiers 59, RT, LT, XE, XS and
XU is defined in the CPT Manual, NCCI Policy Manual, CMS guidelines and our health plan’s
Reimbursement Policy - Modifier 105 – Modifiers 59, XE, XP, XS, XU; Distinct Procedural Service.
Effective 7/1/2016, the following code pairs will not allow modifier 59 to bypass the code pair denial.
MAIN
99381 - 99397
99381 - 99397
99381 - 99397
92002 - 92014
92002 - 92014
99201 - 99215
99201 - 99215
19301 - 19307
19301 - 19307
19301 - 19307
19301 - 19307
19316 and 19318
19316 and 19318
19316 and 19318
19316 and 19318
3/21/2016
DENIED
99173 w mods 59 XE XP XS XU
99174 w mods 59 XE XP XS XU
99177 w mods 59 XE XP XS XU
99174 w mods 59 XE XP XS XU
99177 w mods 59 XE XP XS XU
99174 w mods 59 XE XP XS XU
99177 w mods 59 XE XP XS XU
14000 w mods 59 XE XP XS XU
14001 w mods 59 XE XP XS XU
14301 w mods 59 XE XP XS XU
14302 w mods 59 XE XP XS XU
14000 w mods 59 XE XP XS XU
14001 w mods 59 XE XP XS XU
14301 w mods 59 XE XP XS XU
14302 w mods 59 XE XP XS XU
RATIONALE
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Integral/Incident To
Supplement to CCI version 22.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
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