Medicare Advantage

Medical Policy

Notification

Bundled Procedure Codes

Notification Issued Date:

This version of the policy will become effective 12/31/2025. This policy is being updated to communicate the Company's reimbursement position for procedure codes identified by the Medicare Physician Fee Schedule (MPFS) status indicator T as bundled services and certain procedure codes that are not eligible for separate reimbursement consideration when reported with another specific procedure or service by the same provider, for the same member, on the same date.

Title:

Bundled Procedure Codes

Policy #:

MA00.026y

Policy

The intent of this policy is to communicate procedures or services that are not eligible for reimbursement or not eligible for separate reimbursement consideration by the Company, when billed alone or in conjunction with other services, as outlined in this policy.

Attachments A, B, and C apply to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, and outpatient facility providers billing on a UB-04 claim form or the electronic equivalent, 837i.

Attachment D applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p.

The procedure codes listed in Attachment A are considered "always bundled" and "bundled" services, based on the Medicare Physician Fee Schedule Database (MPFSD) Status B and T Indicators, respectively. Status B procedure codes are considered always bundled into the reimbursement for other services and, therefore, are not eligible for separate reimbursement, whether billed alone or in conjunction with other services. Status T procedure codes are considered bundled into the reimbursement for other services reported by the same provider, for the same member, on the same date and, therefore, are not eligible for separate reimbursement. Participating providers may not bill members for these services.

The procedure codes listed in Attachment B may be covered by the Company; however, they are not eligible for separate reimbursement consideration whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.

The procedure codes listed in Attachment C may be covered by the Company; however, they are not eligible for reimbursement consideration. Participating providers may not bill members for these services.

The procedure codes listed in Attachment D may be covered by the Company; however, they are not eligible for separate reimbursement consideration when reported in conjunction with other services identified in this attachment, by the same provider, for the same member, on the same date. Participating providers may not bill members for these services.

Guidelines

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

The Company takes into consideration the Medicare Physician Fee Schedule Database (MPFSD), the American Medical Association Current Procedure Technology (CPT) Manual, Centers for Medicare & Medicaid Services (CMS) guidelines, Company policies, and other appropriate sources, when determining services listed in this policy.

The MPFSD identifies procedure codes with status B and T indicators. The status B indicator is used when the reimbursement for certain procedure codes is always considered bundled into the reimbursement for other services. The Status T indicator is used when the reimbursement for certain procedure codes is bundled into the reimbursement for other services reimbursed to the same provider, for the same member, on the same date of service.

References

Centers for Medicare & Medicaid Services (CMS). National Physician Fee Schedule Relative Value File. [CMS Web site]. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. Accessed September 15, 2025.

Centers for Medicare & Medicaid Services Medicare Claims Processing Manual. Chapter 23 - Fee Schedule Administration and Coding. Requirements. Table of Contents. (Rev. 4188, 12-28-18). Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. Accessed September 15, 2025.

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)

Attachment A: Always Bundled or Bundled Procedures/Services (MPFSD) Status B and Status T Indicators

Attachment B: Procedures/Services Not Eligible for Separate Reimbursement

Attachment C: Procedures/Services Not Eligible for Reimbursement

Attachment D: Procedures/Services Not Eligible for Separate Reimbursement when reported with another specific Procedure/Service

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Attachment A: Always Bundled or Bundled Procedures/Services (MPFSD) Status B and Status T Indicators

Attachment B: Procedures/Services Not Eligible for Separate Reimbursement

Attachment C: Procedures/Services Not Eligible for Reimbursement

Attachment D: Procedures/Services Not Eligible for Separate Reimbursement when reported with another specific Procedure/Service

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

1/1/2026

Version Issued Date:

1/9/2026

Version Reissued Date: