ModifiedEmblemHealthPolicy RPC20220031

Bundled Services (Commercial and Medicare)

Defines EmblemHealth payment and claim-editing criteria for CPT/HCPCS procedure codes that CMS classifies as bundled or excluded when billed on professional (CMS-1500) claims; applies to physician and non-physician practitioner services and excludes Ambulance, DME, Home Infusion, and Home Care providers.

Policy Summary

PayerEmblemHealth

PolicyBundled Services (Commercial and Medicare)

Policy CodePolicy RPC20220031

Change TypeCode additions/removals and clarifications (2024–2026)

Effective DateJan 1, 2018

Next Review DateN/A

Key ActionDo not separately reimburse CPT/HCPCS codes designated by CMS as Status P or B when billed with an applicable physician service; code-editing will deny status P lines when a non-status-P procedure is present for the same member, same provider, same date.

SourceLink

POLICY UPDATE CHANGES

Added new codes 92629, 92631, 92632, 92634, 92635, 92636, 92637, 92638, 92639, 92641, 92642, A4295, A4296, A4297 to 'Status 'N' CPT/HCPCS Codes' table effective 1/1/2026.

Removed deleted codes with effective date 1/1/2026 including Status 'B' CPT/HCPCS codes 92921, 92929, 92934, 92938, 92944 and OPPS Status 'N' code J7505.

Removed codes J0666, J0668, and J2002 from 'Anesthetic 'Caine' Drugs' table.

Added new CPT codes 38225, 38226, 38227 & 96041 to Status 'B' table.

Removed deleted CPT codes 0537T, 0538T, 0539T from Status 'B' table.

Added HCPCS code J0666 to 'Anesthetic "Caine" Drugs' table.

Removed deleted CPT code 96040 from Status 'B' table for Medicare.

Added codes A4211, A4212, A4220, A4239, A4253, A4256, A4258 & A4259 to Status 'P' table.

Indicated code J2001 as deleted and added J2002, J2003, J2004 to Anesthetic 'Caine' Drugs table.

Clarified inclusion of OPPS Status 'N' codes in the policy.

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.

Coverage and Claim-Editing Criteria

Coverage and claim-editing criteria for bundled/excluded codes

EmblemHealth follows CMS NPFS guidance and will not separately reimburse certain CPT/HCPCS codes with designated bundled/excluded status when billed by professional providers on CMS-1500 claims.

EmblemHealth aligns with CMS NPFS status indicators to determine when services and supplies are ineligible for separate reimbursement.

Status 'B' (Bundled): Do not separately reimburse codes with NPFS Status 'B' when billed with services to which they are incident; modifiers will not override denials for always-bundled services and supplies.

Status 'P' (Bundled/Excluded): EmblemHealth will not separately reimburse codes designated Status 'P'; code-editing software evaluates current and historical claims for the same member, same individual provider, and same date of service. If a non-status-P procedure is present, the status 'P' line is denied. Status 'P' codes pay when billed alone or only with other status 'P' codes.

Status 'T': Codes assigned status 'T' are bundled into services assigned status 'A' or 'R' on the same date by the same individual provider; modifier overrides will not prevent bundling. When two T codes are billed together, EmblemHealth may bundle the lower RVU into the higher RVU.

Operational claim-editing: EmblemHealth uses coding edits and claims-editing software to compare current and historical claim lines; noncompliance may result in denial or recoupment.

Informational lists: Code tables in the document are for informational purposes and are subject to change; inclusion or exclusion of a code does not by itself guarantee coverage or reimbursement.

Coverage stance for status-based bundling

EmblemHealth's stance on payment for CMS-designated status codes and bundled drugs for Commercial and Medicare:

Status 'P' bundling rule: If a status 'P' code is billed for the same member on the same date by the same individual provider and another non-status-'P' procedure is present, the status 'P' line will be denied because payment is subsumed by the other service.

Status 'P' standalone rule: Status 'P' procedure codes will be paid when billed alone or when billed only with other status 'P' codes.

Status 'T' bundling rule: Status 'T' codes are bundled into A or R services provided on the same date by the same individual provider; modifier overrides do not prevent bundling; when two T codes are billed together EmblemHealth may bundle the lower RVU into the higher RVU.

OPPS Status 'N' rule: OPPS Status 'N' items/services are packaged into APC rates and not separately reimbursed; codes with OPPS 'N' that are also not payable under NPFS (status E or X) will not be reimbursed separately.

Payment stance by OPPS status

Coverage stance by code status as listed in the tables:

OPPS Status 'N' (Excluded from OPPS payment): Codes assigned OPPS Status 'N' are excluded from payment under OPPS for Commercial and Medicare; when also not payable under NPFS (E or X) they will not be separately reimbursed.

Status 'B' (Bundled services): Status 'B' CPT/HCPCS codes listed in the tables are considered bundled services and are not separately reimbursed for Commercial and Medicare.

Bundling applicability

Billing applicability and exclusions

Applicable bill type and scope: This policy applies to Physician and Non-physician Practitioner Services and Outpatient Institutional Claims billed on CMS-1500.

Provider exclusions: Policy does not apply to Ambulance, DME, Home Infusion, and Home Care providers.

OPPS Status 'N' inclusion: OPPS Status 'N' codes are incorporated into this policy for outpatient hospital bundling considerations and are reflected in the document's OPPS tables and revision history.

CPT / HCPCS Code Lists and Rules

Status B (Bundled) — selected CPT/HCPCS (Commercial)mixedNot Covered

92358	Bundled — examples of paired codes (see policy)
94005	Bundled — examples of paired codes (see policy)

Status B (Bundled) — selected CPT/HCPCS (Medicare)mixedNot Covered

90887	Bundled — multiple pairings to other CPT/HCPCS codes
92605	Bundled — multiple pairings to other CPT/HCPCS codes
98961	Bundled — multiple pairings to other CPT/HCPCS codes
99070	Bundled — multiple pairings to other CPT/HCPCS codes
99366	Bundled — multiple pairings to other CPT/HCPCS codes
A4300	Bundled — multiple pairings to other HCPCS codes
A4270	Bundled — HCPCS example

Status B — operational updatesmixed

38225	Added CPT code to Status B (effective update)
38226	Added CPT code to Status B (effective update)
38227	Added CPT code to Status B (effective update)
96041	Added CPT code to Status B (effective update)

Status P — Supply/Included Codes (Commercial and Medicare)HCPCSNot Covered

A4310	Status P — supply code; payment subsumed when billed with other non-P services
A4330	Status P — supply code; payment subsumed when billed with other non-P services
A4358	Status P — supply code; payment subsumed when billed with other non-P services
A4455	Status P — supply code; payment subsumed when billed with other non-P services
A5055	Status P — supply code; payment subsumed when billed with other non-P services
A5112	Status P — supply code; payment subsumed when billed with other non-P services
A6215	Status P — supply code; payment subsumed when billed with other non-P services

Status P — operational rulesmixed

Rule	Status P codes pay when billed alone or with other Status P codes; otherwise denied when billed with a non-Status P service by the same provider on same DOS. EmblemHealth code editing evaluates current and historical claim lines for same member, same individual physician, same date of service.

Status P — Code list (partial) — selected HCPCS pairingsHCPCSNot Covered

A4311	Related to A4310 pairing (informational)
A4312	Related to A4310 pairing (informational)
A4313	Related to A4310 pairing (informational)
A4314	Related to A4310 pairing (informational)
A4315	Related to A4310 pairing (informational)
A4316	Related to A4310 pairing (informational)
A4320	Related to A4310 pairing (informational)
A4322	Related to A4310 pairing (informational)
A4326	Related to A4310 pairing (informational)
A4327	Related to A4310 pairing (informational)

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Status P — Bundled services (partial)HCPCSNot Covered

A4358	Multiple A43xx series supply codes included
A4455	Multiple A44xx series supply codes included
A5055	Multiple A50xx series supply codes included
A5112	Multiple A51xx series supply codes included
A6215	A62xx series — bundled supply codes included

Status T — examples (partial)CPTNot Covered

36591	Status T — bundles into related vascular access and infusion services (examples: 36592, 36598)
36592	Status T — related pairing
36598	Status T — related pairing
94760	Status T — respiratory procedure — may bundle with higher RVU code
94761	Status T — respiratory procedure — may bundle with higher RVU code
96523	Status T — example immunization administration pairing
G0117	Status T — examples listed by CMS
G0118	Status T — examples listed by CMS

OPPS Status N — selected OPPS/HCPCS (Commercial and Medicare)HCPCSNot Covered

92642	OPPS Status N — outpatient hospital bundled code (example pairings to A42xx series)
A4222	OPPS Status N — examples of pairings with 9262x codes
A4280	OPPS Status N — examples
A4378	OPPS Status N — bundled services examples
A4481	OPPS Status N — bundled services examples
A4614	OPPS Status N — bundled services examples
A4629	OPPS Status N — bundled services examples

OPPS Status N — policy notemixed

Note	EmblemHealth follows CMS OPPS Fee Schedule for OPPS Status N codes; codes with OPPS 'N' that are not payable under NPFS will not be separately reimbursed. Inclusion is informational and subject to change.

Bundled Services — recent updatesmixed

J0666	Added anesthetic HCPCS (Anesthetic 'Caine' Drugs)
J2002	Added anesthetic/updated code
A4211	Added to Status P effective 5/10/2025
A4212	Added to Status P effective 5/10/2025
A4220	Added to Status P effective 5/10/2025
A4239	Added to Status P effective 5/10/2025
A4253	Added to Status P effective 5/10/2025
A4256	Added to Status P effective 5/10/2025
A4258	Added to Status P effective 5/10/2025
A4259	Added to Status P effective 5/10/2025

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Billing, Denial, and Provider Impact

Denial Risk

Status P — Claim editing and denial process

EmblemHealth will not separately reimburse for certain CPT/HCPCS codes designated by CMS NPFS as Status 'P'. Claim-editing evaluates current and historical claim lines to determine if a billed Status 'P' code is subsumed by other non-P services on the same date of service for the same member and same individual physician or other health care professional. Providers should bill with awareness that Status 'P' codes pay when billed alone or only with other Status 'P' codes; otherwise they will be denied as bundled.

EmblemHealth code editing evaluates current and historical claim lines for the same member, same individual physician or other health care professional, and same date of service.
If a non-Status 'P' procedure is present on the claim, the line billed with a Status 'P' code will be denied (payment is considered subsumed).
Status 'P' codes will pay when billed alone.
Status 'P' codes will pay when billed only with other Status 'P' codes.

Key Definitions and Status Indicators

inv-26: Incidental Procedure

DefinitionAn incidental procedure is performed at the same time as a more complex primary procedure, requires minimal additional provider resources, and is considered not necessary to the performance of the primary procedure.

Billing implicationWhen an incidental procedure is provided with a primary physician service, payment for the incidental procedure is typically bundled into the payment for the primary service.

Policy alignmentEmblemHealth aligns with CMS guidance that incidental procedures are not separately reimbursed when they are included in a primary service.

inv-27: NPFS Status Indicators (A, B, E, P, R, T, X)

NPFS status indicatorsCMS NPFS status indicators (A, B, E, P, R, T, X) describe payment treatment under the physician fee schedule.

Examples

Policy Summary

PayerEmblemHealth

PolicyBundled Services (Commercial and Medicare)

Policy CodePolicy RPC20220031

Change TypeCode additions/removals and clarifications (2024–2026)

Effective DateJan 1, 2018

Next Review DateN/A

SourceLink

On This Page

Billing Rule

OPPS Excluded Codes (Status N)

Certain CPT/HCPCS codes are excluded from OPPS payment per CMS (OPPS Status 'N'). These codes are not reimbursed under the OPPS methodology by EmblemHealth for Commercial and Medicare where applicable. The listed codes are based on CMS publications and are subject to change; inclusion does not in itself guarantee coverage or reimbursement.

OPPS Status 'N' codes are excluded from OPPS payment for Commercial and Medicare.
Lists of affected CPT/HCPCS codes are maintained and updated periodically (see policy revision history for recent additions/removals).
Providers should reference the current CMS NPFS and EmblemHealth updates when billing outpatient institutional claims.

Billing Rule

Bundled Services and Bundled Drug Codes (Status B and related)

EmblemHealth follows CMS NPFS Status 'B' designations: codes identified as bundled (Status 'B') will not be separately reimbursed. Modifiers will not override denials for always-bundled services. The Status 'B' list and other bundled-service groupings (including anesthetic 'Caine' drugs and other bundled supplies) are maintained from CMS updates and EmblemHealth revisions.

Status 'B' codes are bundled and not separately payable; modifiers do not override bundling for always-bundled services.
Anesthetic 'Caine' HCPCS drugs are considered bundled and not separately reimbursed when billed with a medical or surgical procedure.
EmblemHealth maintains tables of bundled services (Status B, T, P, and OPPS Status N) for informational purposes; code lists are subject to change.
Inclusion or exclusion of a code in these lists does not by itself constitute coverage or guarantee reimbursement.