Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
11970
DENIED
19370
19301
14000
19301
14001
NCCI Policy Manual
Integral/Incident To
19301
14301
NCCI Policy Manual
Integral/Incident To
19301
14320
NCCI Policy Manual
Integral/Incident To
19302
14000
NCCI Policy Manual
Integral/Incident To
19302
14001
NCCI Policy Manual
Integral/Incident To
19302
14301
NCCI Policy Manual
Integral/Incident To
19302
14302
NCCI Policy Manual
Integral/Incident To
19303
14000
NCCI Policy Manual
Integral/Incident To
19303
14001
NCCI Policy Manual
Integral/Incident To
19303
14301
NCCI Policy Manual
Integral/Incident To
19303
14302
NCCI Policy Manual
Integral/Incident To
19304
14000
NCCI Policy Manual
Integral/Incident To
19304
14001
NCCI Policy Manual
Integral/Incident To
19304
14301
NCCI Policy Manual
Integral/Incident To
19304
14302
NCCI Policy Manual
Integral/Incident To
19305
14000
NCCI Policy Manual
Integral/Incident To
19305
14001
NCCI Policy Manual
Integral/Incident To
19305
14301
NCCI Policy Manual
Integral/Incident To
3/21/2017
RATIONALE
NCCI Policy Manual v 15.3
Chapter I B
NCCI Policy Manual
Integral/Incident To
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 1 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
19305
DENIED
14302
RATIONALE
NCCI Policy Manual
Integral/Incident To
19306
14000
NCCI Policy Manual
Integral/Incident To
19306
14001
NCCI Policy Manual
Integral/Incident To
19306
14301
NCCI Policy Manual
Integral/Incident To
19306
14302
NCCI Policy Manual
Integral/Incident To
19307
14000
NCCI Policy Manual
Integral/Incident To
19307
14001
NCCI Policy Manual
Integral/Incident To
19307
14301
NCCI Policy Manual
Integral/Incident To
19307
14302
NCCI Policy Manual
Integral/Incident To
19316
14000
NCCI Policy Manual
Integral/Incident To
19316
14001
NCCI Policy Manual
Integral/Incident To
19316
14301
NCCI Policy Manual
Integral/Incident To
19316
14302
NCCI Policy Manual
Integral/Incident To
19316
19342
NCCI Policy Manual
Integral/Incident To
19318
14000
NCCI Policy Manual
Integral/Incident To
19318
14001
NCCI Policy Manual
Integral/Incident To
19318
14301
NCCI Policy Manual
Integral/Incident To
19318
14302
NCCI Policy Manual
Integral/Incident To
19364
14000
NCCI Policy Manual
Integral/Incident To
19364
14001
NCCI Policy Manual
Integral/Incident To
19364
14301
NCCI Policy Manual
Integral/Incident To
3/21/2017
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 2 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
19364
DENIED
14302
RATIONALE
NCCI Policy Manual
Integral/Incident To
19364
15734
NCCI Policy Manual
Integral/Incident To
19364
20926
19364
35761
22551
22830
22554
22830
22612
22214
22612
22325
22630
22214
22630
22325
22633
22214
22633
22325
NCCI Policy Manual
Integral/Incident To
NCCI Policy Manual
Integral/Incident To
NCCI Policy Manual v 17.3
Chapter IV H8
NCCI Policy Manual v 17.3
Chapter IV H8
NCCI Policy Manual
Integral/Incident To
NCCI Policy Manual
Integral/Incident To
NCCI Policy Manual
Integral/Incident To
NCCI Policy Manual
Integral/Incident To
NCCI Policy Manual
Integral/Incident To
NCCI Policy Manual
Integral/Incident To
22840
22850
NCCI Policy Manual v 15.3
Chapter IV F 7
22840
22852
NCCI Policy Manual v 15.3
Chapter IV F 7
22842
22850
NCCI Policy Manual v 15.3
Chapter IV F 7
22845
22830
NCCI Policy Manual v 17.3
Chapter IV H8
22846
22830
NCCI Policy Manual v 17.3
Chapter IV H8
22849
22830
NCCI Policy Manual v 17.3
Chapter IV H8
22853
22830
NCCI Policy Manual v 17.3
Chapter IV H8
22853
22850
NCCI Policy Manual v 17.3
Chapter IV H8
22853
22855
NCCI Policy Manual v 17.3
Chapter IV H8
3/21/2017
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 3 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
22854
DENIED
22830
RATIONALE
NCCI Policy Manual v 17.3
Chapter IV H8
22854
22850
NCCI Policy Manual v 17.3
Chapter IV H8
22854
22855
NCCI Policy Manual v 17.3
Chapter IV H8
22855
22845
NCCI Policy Manual v 15.3
Chapter IV F 7
22859
22830
NCCI Policy Manual v 17.3
Chapter IV H8
22859
22850
NCCI Policy Manual v 17.3
Chapter IV H8
22859
22855
NCCI Policy Manual v 17.3
Chapter IV H8
23120
29822
NCCI Policy Manual v 15.3
Chapter IV E
23120
29823
NCCI Policy Manual v 15.3
Chapter IV E
23130
29822
NCCI Policy Manual v 15.3
Chapter IV E
23130
29823
NCCI Policy Manual v 15.3
Chapter IV E
23410
29822
NCCI Policy Manual v 15.3
Chapter IV E
23410
29823
NCCI Policy Manual v 15.3
Chapter IV E
23410
29826
NCCI Policy Manual v 15.3
Chapter IV E
23412
29822
NCCI Policy Manual v 15.3
Chapter IV E
23412
29826
NCCI Policy Manual v 15.3
Chapter IV E
23430
29822
NCCI Policy Manual v 15.3
Chapter IV E
23455
29807
NCCI Policy Manual v 15.3
Chapter IV E
23455
29822
NCCI Policy Manual v 15.3
Chapter IV E
23670
29822
NCCI Policy Manual v 15.3
Chapter IV E
27429
29888
NCCI Policy Manual v 15.3
Chapter IV E
3/21/2017
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 4 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
27446
DENIED
29881
RATIONALE
NCCI Policy Manual v 15.3
Chapter IV E
29806
29807
NCCI Policy Manual v 15.3
Chapter IV E
29806
29819
NCCI Policy Manual v 15.3
Chapter IV E
29806
29823
NCCI Policy Manual v 15.3
Chapter IV E
29824
29822
NCCI Policy Manual v 15.3
Chapter IV E
29824
29823
NCCI Policy Manual v 15.3
Chapter IV E
29827
29822
NCCI Policy Manual v 15.3
Chapter IV E
29827
29823
NCCI Policy Manual v 15.3
Chapter IV E
29828
29822
NCCI Policy Manual v 15.3
Chapter IV E
29861
29999
NCCI Policy Manual
Incident To Service
29862
29999
29863
29999
29879
29875
29880
29875
29880
29876
29881
29875
29888
29875
29914
27006
29914
27036
29914
27062
29914
27071
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual v 15.3
Chapter I J
NCCI Policy Manual v 15.3
Chapter I J
NCCI Policy Manual v 15.3
Chapter I J
NCCI Policy Manual v 15.3
Chapter I J
NCCI Policy Manual v 15.3
Chapter I J
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
3/21/2017
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 5 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
29914
DENIED
27187
29914
27305
29914
29861
29914
29862
29914
29863
29914
29999
29914
76000
29914
76001
29915
27006
29915
27036
29915
27062
29915
27071
29915
27187
29915
27305
29915
29861
29915
29862
29915
29863
29915
29999
29915
76000
29915
76001
29116
27006
29916
27036
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 6 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
29916
DENIED
27062
29916
27071
29916
27187
29916
27305
29916
29861
29916
29862
29916
29863
29916
29999
29916
76000
29916
76001
30465
20912
30520
20912
33249
33241
43279
43281
43279
43282
43289
43235
43644
43235
43644
43281
43644
43282
43644
43774
43645
43281
43645
43282
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 7 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
43645
DENIED
43774
43770
43235
43770
43281
43770
43282
43770
43774
43771
43281
43771
43282
43771
43774
43773
43281
43773
43282
43773
43774
43775
43235
43775
43281
43775
43282
43775
43774
43848
43235
47562
74300
47562
74301
47564
74300
47564
74301
47600
74300
47600
74301
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 8 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
49505
DENIED
55450
49505
55500
49505
55520
49505
55530
49507
55450
49507
55500
49507
55520
49507
55530
49520
55450
49520
55500
49520
55520
49520
55530
59400
12041
59400
12042
59409
12041
59409
12042
59410
12041
59410
12042
59510
59514
59510
59515
59618
59620
59618
59622
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual v 16.3
Chapter VII I-6
NCCI Policy Manual v 16.3
Chapter VII I-6
NCCI Policy Manual v 16.3
Chapter VII I-6
NCCI Policy Manual v 16.3
Chapter VII I-6
NCCI Policy Manual v 16.3
Chapter VII I-6
NCCI Policy Manual v 16.3
Chapter VII I-6
CPT Assistant
August 2002
CPT Assistant
August 2002
CPT Assistant
August 2002
CPT Assistant
August 2002
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 9 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
63047
DENIED
22852
67901
15823
67904
15823
70450
73222
70480
73221
77065
76499
77065
77061
77065
77062
77065
77063
77065
G0279
77066
76499
77066
77061
77066
77062
77066
77063
77066
G0279
77067
76499
77067
77061
77067
77062
77067
77063
92002
99173
92002
99174
92002
99177
92004
99173
3/21/2017
RATIONALE
NCCI Policy Manual v 15.3
Chapter IV F 7
NCCI Policy Manual v 15.3
Chapter VIII D 12
NCCI Policy Manual v 15.3
Chapter VIII D 12
CPT Text/Definition
NCCI Policy Manual v 15.3
Chapter I H 3E
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 10 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
92004
DENIED
99174
92004
99177
92012
99173
92012
99174
92012
99177
92014
99173
92014
99174
92014
99177
95941
G0453
99201
99173
99201
99174
99201
99177
99201
S0610
99201
S0612
99202
99173
99202
99174
99202
99177
99202
S0610
99202
S0612
99203
99173
99203
99174
99203
99177
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 11 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
99203
DENIED
S0610
99203
S0612
99204
99173
99204
99174
99204
99177
99204
S0610
99204
S0612
99205
99173
99205
99174
99205
99177
99205
S0610
99205
S0612
99211
99173
99211
99174
99211
99177
99211
S0610
99211
S0612
99212
99173
99212
99174
99212
99177
99212
S0610
99212
S0612
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 12 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
99213
DENIED
99173
99213
99174
99213
99177
99213
S0610
99213
S0612
99214
99173
99214
99174
99214
99177
99214
S0610
99214
S0612
99215
99173
99215
99174
99215
99177
99215
S0610
99215
S0612
99381
96127
99381
99173
99381
99174
99381
99177
99382
96127
99382
99173
99382
99174
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 13 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
99382
DENIED
99177
99383
96127
99383
99173
99383
99174
99383
99177
99384
96127
99384
99173
99384
99174
99384
99177
99384
G0101
99384
G0102
99384
S0610
99384
S0612
99385
96127
99385
99173
99385
99174
99385
99177
99385
G0101
99385
G0102
99385
S0610
99385
S0612
99386
96127
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 14 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
99386
DENIED
99173
99386
99174
99386
99177
99386
G0101
99386
G0102
99386
S0610
99386
S0612
99387
96127
99387
99173
99387
99174
99387
99177
99387
G0101
99387
G0102
99387
S0610
99387
S0612
99391
96127
99391
99173
99391
99174
99391
99177
99392
96127
99392
99173
99392
99174
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 15 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
99392
DENIED
99177
99393
96127
99393
99173
99393
99174
99393
99177
99394
96127
99394
99173
99394
99174
99394
99177
99394
G0101
99394
G0102
99394
S0610
99394
S0612
99395
96127
99395
99173
99395
99174
99395
99177
99395
G0101
99395
G0102
99395
S0610
99395
S0612
99396
96127
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 16 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
99396
DENIED
99173
99396
99174
99396
99177
99396
G0101
99396
G0102
99396
S0610
99396
S0612
99397
96127
99397
99173
99397
99174
99397
99177
99397
G0101
99397
G0102
99397
S0610
99397
S0612
G0101
99201
G0101
99202
G0101
99203
G0101
99204
G0101
99205
G0101
99211
G0101
99212
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 17 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
G0101
DENIED
99213
G0101
99214
G0101
99215
G0202
76499
G0202
77061
G0202
77062
G0202
77063
G0202
G0279
G0204
76499
G0204
77061
G0204
77062
G0204
77063
G0204
G0279
G0206
76499
G0206
77061
G0206
77062
G0206
77063
G0206
G0279
S0610
G0101
S0612
G0101
S2066
14301
S2066
20926
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 18 of 19
Code Pair Edits Do Not Bypass with Modifiers 59 RT LT XE XP XS XU
Our health plan has determined that the following code pairs are typically not appropriately reported
together with modifiers 59, RT, LT, XE, XS XU. Proper use of modifiers 59, RT, LT, XE, XS, XU are
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 4/1/2017 the following code pairs will not allow the bypass modifiers to bypass the code pair
denial.
MAIN
S2066
DENIED
15734
S2066
35761
S2067
14301
S2067
20926
S2067
15734
S2067
35761
S2068
14301
S2068
20926
S2068
15734
S2068
35761
3/21/2017
RATIONALE
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
NCCI Policy Manual
Incident To Service
Supplement to CCI version 23.1
CPT® is a trademark of the American Medical Association.
The appearance of HCPCS/CPT® codes does not necessarily indicate coverage.
Page 19 of 19