ModifiedAnthemPolicy C-08003

Bundled Services and Supplies — Professional reimbursement

Defines which professional services and supplies are ineligible for separate reimbursement (always bundled, bundled with specific services, or bundled when reported with any other service) for Anthem commercial plans; affects professional providers submitting claims.

Policy Summary

PayerAnthem

PolicyBundled Services and Supplies — Professional reimbursement

Policy CodePolicy C-08003

Change TypeCoding and bundling updates

Effective DateJul 1, 2024

Next Review Date

Key ActionUse updated Section 1 and Section 2 code tables and follow modifier limitations when submitting claims; services must meet authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

Updated coding lists in Section 1: added codes G0310-G0318, G2212, M0001-M0005, M1150-M1210, HCPCS S0353 and S0354; removed 99000, 99001 and H0048.

Section 2 code pair changes: removed consultation and certain observation codes from specific code pairs (e.g., removed 99217-99220, 99241-99245, 99252-99255 from 69209/69210 pair).

3policy sections

multiplerecent code additions

07/01/2024effective

04/01/2024last review

Policy Summary

PayerAnthem

PolicyBundled Services and Supplies — Professional reimbursement

Policy CodePolicy C-08003

Change TypeCoding and bundling updates

Effective DateJul 1, 2024

Next Review Date

Key ActionUse updated Section 1 and Section 2 code tables and follow modifier limitations when submitting claims; services must meet authorization and medical necessity guidelines.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

HCPCS 'S' codes added

Bundling and Denial Rules

inv-01: Bundling criteria — policy-level rules, denial logic by section

Bundling rules and denial logic are organized by policy section. Denials for always-bundled items and most specified code-pair bundles are not overridden by modifiers.

Section 1 — Always bundled: Specific CPT and HCPCS codes listed in the Section 1 coding grid are not eligible for separate reimbursement when billed with another service or when reported as a stand-alone service; modifiers will not override denials for always-bundled services.

Section 2 — Code-pair bundling: Procedures, services and supplies identified in Section 2 are not separately reimbursable when reported with a listed primary procedure/service; in most cases modifiers will not override the denial.

Section 3 — Bundled with any other procedure: Services that are reimbursable when reported alone but not eligible for separate reimbursement when performed with any other procedure, service, or supply; modifiers 59, XE, XP, XS or XU will not override denials.

Modifier limitations: Modifiers including 59, XE, XP, XS, XU and X will not override denials for always-bundled services, specified code-pair edits, or services bundled when reported with any other procedure.

Billing and documentation expectation: Claims must be submitted using standard CPT/HCPCS codes and supported by the medical record; failure to follow billing requirements may result in rejection, denial, or recoupment.

Recent updates: Coding and code-pair revisions approved 04/01/2024 and effective 07/01/2024 include additions and removals to Section 1 and modifications to Section 2 code-pair relationships.

inv-02: Bundling criteria and specific denial rules — code-level bundling when identified in code tables

Specific code- and scenario-level bundling rules that trigger denial or inclusion as part of another service.

Always bundled HCPCS 'S' codes: Certain HCPCS Level II 'S' codes (for example S0257, S1015, S1016, S3005, S4005, S4011, S4022, S4025, S4027, S4028, S4035, S4037, S4040, S4042, S8096, S8097, S8100, S8101, S8415, S9098, S9110, S9900, S9901) are identified as always bundled and not separately reimbursable.

G code consolidations and additions: Specific G codes (including G0276, G0431, G0434, and G0466-G0470) are consolidated/added to the bundled list; G0431 and G0434 (previously used for drug screening) are no longer applicable for drug screening and are treated as bundled per policy.

Digital breast tomosynthesis (DBT): DBT codes (77061, 77062, 77063 and G0279) are added to the always-bundled 3D imaging services; unspecified code 76499 may be bundled to mammography or breast MRI where applicable.

Electrodes and lead wires with electrical stimulator supplies:

Code Lists and Coding Rules

Always-bundled HCPCS 'S' codesHCPCS

S0257	Non-covered/plan-specific program/service
S1015	Non-covered/plan-specific program/service
S1016	Non-covered/plan-specific program/service
S3005	Non-covered/plan-specific program/service
S4005	Non-covered/plan-specific program/service
S4011	Non-covered/plan-specific program/service
S4022	Non-covered/plan-specific program/service
S4025	Non-covered/plan-specific program/service
S4027	Non-covered/plan-specific program/service
S4028	Non-covered/plan-specific program/service

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Always-bundled 'S' codes (policy history additions)HCPCS

S9900	Non-covered/plan-specific program/service
S9901	Non-covered/plan-specific program/service
S0353	Non-covered/plan-specific program/service
S0354	Non-covered/plan-specific program/service

G code consolidations and DBT additionsHCPCS

G0276	Drug screen/drug testing related code
G0431	Drug screen / screening related (FQHC/reporting)
G0434	Drug screen / screening related (FQHC/reporting)
G0466	CMS demonstration/other reporting
G0467	CMS demonstration/other reporting
G0468	CMS demonstration/other reporting
G0469	CMS demonstration/other reporting
G0470	CMS demonstration/other reporting
G0279	Digital breast tomosynthesis
77061	Digital breast tomosynthesis, unilateral

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Digital Breast Tomosynthesis codesmixed

77061	Digital breast tomosynthesis, unilateral
77062	Digital breast tomosynthesis, bilateral
77063	Mammography with tomosynthesis
G0279	Tomosynthesis related HCPCS
76499	Unspecified procedure; may be bundled when DBT reported with mammography or breast MRI

Electrical stimulator supplies bundlingHCPCS

A4595	Electrical stimulator supplies, includes electrodes and lead wires
A4556	Electrodes
A4557	Lead wires

Home infusion therapy per diem bundlingHCPCS

S5497	Per diem home infusion therapy catheter care/maintenance — includes care, equipment, and supplies
S9810	Drug administration professional pharmacy services (do not use with per diem codes)
E0776	IV pole — equipment included with per diem
99000	Related non-covered/administrative service (included per completeness review)
99001	Related non-covered/administrative service (included per completeness review)
H0048	Behavioral health; case management, each 15 minutes (included per completeness review)

Billing, Authorization, and Modifier Guidance

Documentation Required

Authorization and billing expectations

Services must meet authorization and medical necessity guidelines and be billed using industry-standard, compliant codes. Providers are responsible for documentation that supports the codes billed. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial and/or recovery/recoupment of payment.

Use CPT, HCPCS, and/or revenue codes that are fully supported in the medical record and office notes.
Ensure prior authorization requirements (when applicable) are met before rendering services.
Maintain documentation that substantiates the medical necessity and the specific services billed.

Billing Rule

Modifier cross-reference update

Policy Section Definitions and Terms

Section 1 — Services and supplies always bundled (inv-13)

DefinitionSection 1 lists CPT and HCPCS Level II codes that are not eligible for separate reimbursement when reported with another service or when reported as a stand-alone service.

Common characteristicServices without direct (face-to-face) patient contact are generally considered integral and not separately reimbursable.

Modifier policyModifiers will not override denials for the always-bundled services and supplies listed in Section 1.

Section 2 — Code-pair bundling (inv-14)

DefinitionSection 2 describes procedures, services and supplies that are not eligible for separate reimbursement when reported with another specific procedure, service or supply (code-pair relationships).

Modifier policy

A4556 (electrodes) and/or A4557 (lead wires) reported with A4595 (electrical stimulator supplies) on the same date of service and/or within 30 days will be denied; A4595 includes the electrodes and wires.

Home infusion per diem bundling: Per diem home infusion therapy (S5497) includes catheter care/maintenance and all necessary equipment and supplies; S9810 (home infusion professional pharmacy/drug administration) should not be used with per diem codes and is not separately reimbursable when reported with S5497; equipment such as E0776 (IV pole) is considered included when billed with S5497.

Electrodes/wires timing threshold: Denial for A4556/A4557 with A4595 applies when reported on the same date of service and/or within 30 days.

Modifier cross-reference update: the XE, XP, XS, and XU modifiers have been added to the cross-reference for the Modifier 59 policy. When reporting these distinct procedural service modifiers, ensure they are applied per code set and documentation guidance and only when supported by the medical record. Improper use may lead to claim denials or recoupment.

Affected modifiers added: XE, XP, XS, XU (in addition to modifier 59) for cross-reference purposes.
Apply XE (separate encounter), XP (separate practitioner), XS (separate structure), or XU (unusual non-overlapping service) only when documentation clearly supports the distinct service.
Claims billed with these modifiers should follow the same billing rules and medical necessity requirements as modifier 59; unsupported modifier use may be denied.

In most cases, modifiers will not override the denial when reported with the specified service or supply.

ExampleElectrodes (A4556) and/or lead wires (A4557) reported with electrical stimulator supplies (A4595) within the specified time window will be denied per Section 2 rules.

Section 3 — Standalone-only services (inv-15)

DefinitionSection 3 lists services that are eligible for reimbursement when reported alone but are not eligible for separate reimbursement when performed with any other procedure, service, or supply.

Modifier policyModifiers 59, XE, XP, XS or XU will not override denials for services in Section 3 when reported with any other procedure, service or supply.

Practical effectIf a Section 3 service is billed with any additional procedure on the same claim, separate reimbursement will be denied even if an X- or 59-series modifier is appended.

Bundled Services — concept (inv-16)

ConceptBundled services are those that are considered part of another service and therefore are not eligible for separate reimbursement.

How it is appliedThe policy groups bundled services into three sections: always bundled (Section 1), bundled with specific other services (Section 2), and bundled when reported with any other procedure (Section 3).

Billing implicationWhen a service is identified as bundled, claims for that service submitted separately or with the primary service will be denied; modifiers generally will not override.

Per diem home infusion therapy (S5497) — bundling (inv-17)

Scope of S5497S5497 is a per diem home infusion therapy catheter care/maintenance code that includes care and all necessary equipment and supplies.

Do not report separatelyDo not report home infusion professional pharmacy services (S9810) or equipment (E0776) separately with S5497; S9810 instructions state not to use with any per diem code.

Example bundled itemsE0776 (IV pole) and other necessary equipment and supplies are considered included when S5497 is billed.