bluecross blueshield of tennessee commercial code bundling ...€¦ · code bundling rules subject...
TRANSCRIPT
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Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90281 36591 NCCI
90281 36592 NCCI
90281 90281 BCBST
90281 J1460 BCBST
90281 J1470 BCBST
90281 J1480 BCBST
90281 J1490 BCBST
90281 J1500 BCBST
90281 J1510 BCBST
90281 J1520 BCBST
90281 J1530 BCBST
90281 J1540 BCBST
90281 J1550 BCBST
90281 J1560 BCBST
90283 36591 NCCI
90283 36592 NCCI
90283 90283 BCBST
90283 J1561 BCBST
90283 J1566 BCBST
90283 J1568 BCBST
90283 J1569 BCBST
90283 J1572 BCBST
90284 36591 NCCI
90284 36592 NCCI
90284 90284 BCBST
90284 J1562 BCBST
90287 36591 NCCI
90287 36592 NCCI
90287 90287 BCBST
90288 36591 NCCI
90288 36592 NCCI
90288 90288 BCBST
90291 36591 NCCI
90291 36592 NCCI
90291 90291 BCBST
90291 J0850 BCBST
90296 36591 NCCI
90296 36592 NCCI
90296 90296 BCBST
90371 36591 NCCI
90371 36592 NCCI
90371 90371 BCBST
90371 J1571 BCBST
90375 36591 NCCI
90375 36592 NCCI
90375 90375 BCBST
90375 90376 NCCI
Comprehensive ComponentCode Code Source
90376 36591 NCCI
90376 36592 NCCI
90376 90376 BCBST
90378 36000 NCCI
90378 36410 NCCI
90378 36591 NCCI
90378 36592 NCCI
90384 36591 NCCI
90384 36592 NCCI
90384 90384 BCBST
90384 J2788 BCBST
90384 J2790 BCBST
90385 36591 NCCI
90385 36592 NCCI
90385 90385 BCBST
90385 J2788 BCBST
90386 36591 NCCI
90386 36592 NCCI
90386 90386 BCBST
90386 J2792 BCBST
90389 36591 NCCI
90389 36592 NCCI
90389 90389 BCBST
90393 36591 NCCI
90393 36592 NCCI
90393 90393 BCBST
90396 36591 NCCI
90396 36592 NCCI
90396 90396 BCBST
90399 36591 NCCI
90399 36592 NCCI
90460 36591 NCCI
90460 36592 NCCI
90460 90471 NCCI
90460 90473 NCCI
90460 96160 NCCI
90460 96161 NCCI
90460 96372 NCCI
90460 96377 NCCI
90460 99201 NCCI
90460 99202 NCCI
90460 99203 NCCI
90460 99204 NCCI
90460 99205 NCCI
90460 99211 NCCI
90460 99212 NCCI
90460 99213 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 1 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90460 99214 NCCI
90460 99215 NCCI
90460 99241 NCCI
90460 99242 NCCI
90460 99243 NCCI
90460 99244 NCCI
90460 99245 NCCI
90460 99281 NCCI
90460 99282 NCCI
90460 99283 NCCI
90460 99284 NCCI
90460 99285 NCCI
90460 99381 NCCI
90460 99382 NCCI
90460 99383 NCCI
90460 99384 NCCI
90460 99385 NCCI
90460 99386 NCCI
90460 99387 NCCI
90460 99391 NCCI
90460 99392 NCCI
90460 99393 NCCI
90460 99394 NCCI
90460 99395 NCCI
90460 99396 NCCI
90460 99397 NCCI
90460 99401 NCCI
90460 99402 NCCI
90460 99403 NCCI
90460 99404 NCCI
90460 99406 NCCI
90460 99407 NCCI
90460 99408 NCCI
90460 99409 NCCI
90460 99411 NCCI
90460 99412 NCCI
90460 99497 NCCI
90460 G0008 NCCI
90460 G0009 NCCI
90460 G0010 NCCI
90460 G0463 NCCI
90461 36591 NCCI
90461 36592 NCCI
90461 96160 NCCI
90461 96161 NCCI
90461 99201 NCCI
90461 99202 NCCI
Comprehensive ComponentCode Code Source
90461 99203 NCCI
90461 99204 NCCI
90461 99205 NCCI
90461 99211 NCCI
90461 99212 NCCI
90461 99213 NCCI
90461 99214 NCCI
90461 99215 NCCI
90461 99241 NCCI
90461 99242 NCCI
90461 99243 NCCI
90461 99244 NCCI
90461 99245 NCCI
90461 99281 NCCI
90461 99282 NCCI
90461 99283 NCCI
90461 99284 NCCI
90461 99285 NCCI
90461 99381 NCCI
90461 99382 NCCI
90461 99383 NCCI
90461 99384 NCCI
90461 99385 NCCI
90461 99386 NCCI
90461 99387 NCCI
90461 99391 NCCI
90461 99392 NCCI
90461 99393 NCCI
90461 99394 NCCI
90461 99395 NCCI
90461 99396 NCCI
90461 99397 NCCI
90461 99401 NCCI
90461 99402 NCCI
90461 99403 NCCI
90461 99404 NCCI
90461 99406 NCCI
90461 99407 NCCI
90461 99408 NCCI
90461 99409 NCCI
90461 99411 NCCI
90461 99412 NCCI
90461 99497 NCCI
90461 G0463 NCCI
90471 36591 NCCI
90471 36592 NCCI
90471 90471 BCBST
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 2 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90471 90473 NCCI
90471 96160 NCCI
90471 96161 NCCI
90471 99201 NCCI
90471 99202 NCCI
90471 99203 NCCI
90471 99204 NCCI
90471 99205 NCCI
90471 99211 NCCI
90471 99212 NCCI
90471 99213 NCCI
90471 99214 NCCI
90471 99215 NCCI
90471 99241 NCCI
90471 99242 NCCI
90471 99243 NCCI
90471 99244 NCCI
90471 99245 NCCI
90471 99281 NCCI
90471 99282 NCCI
90471 99283 NCCI
90471 99284 NCCI
90471 99285 NCCI
90471 99381 NCCI
90471 99382 NCCI
90471 99383 NCCI
90471 99384 NCCI
90471 99385 NCCI
90471 99386 NCCI
90471 99387 NCCI
90471 99391 NCCI
90471 99392 NCCI
90471 99393 NCCI
90471 99394 NCCI
90471 99395 NCCI
90471 99396 NCCI
90471 99397 NCCI
90471 99401 NCCI
90471 99402 NCCI
90471 99403 NCCI
90471 99404 NCCI
90471 99406 NCCI
90471 99407 NCCI
90471 99408 NCCI
90471 99409 NCCI
90471 99411 NCCI
90471 99412 NCCI
Comprehensive ComponentCode Code Source
90471 99497 NCCI
90471 G0008 NCCI
90471 G0009 NCCI
90471 G0010 NCCI
90471 G0463 NCCI
90472 36591 NCCI
90472 36592 NCCI
90472 96160 NCCI
90472 96161 NCCI
90472 99201 NCCI
90472 99202 NCCI
90472 99203 NCCI
90472 99204 NCCI
90472 99205 NCCI
90472 99211 NCCI
90472 99212 NCCI
90472 99213 NCCI
90472 99214 NCCI
90472 99215 NCCI
90472 99241 NCCI
90472 99242 NCCI
90472 99243 NCCI
90472 99244 NCCI
90472 99245 NCCI
90472 99281 NCCI
90472 99282 NCCI
90472 99283 NCCI
90472 99284 NCCI
90472 99285 NCCI
90472 99381 NCCI
90472 99382 NCCI
90472 99383 NCCI
90472 99384 NCCI
90472 99385 NCCI
90472 99386 NCCI
90472 99387 NCCI
90472 99391 NCCI
90472 99392 NCCI
90472 99393 NCCI
90472 99394 NCCI
90472 99395 NCCI
90472 99396 NCCI
90472 99397 NCCI
90472 99401 NCCI
90472 99402 NCCI
90472 99403 NCCI
90472 99404 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 3 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90472 99406 NCCI
90472 99407 NCCI
90472 99408 NCCI
90472 99409 NCCI
90472 99411 NCCI
90472 99412 NCCI
90472 99497 NCCI
90472 G0463 NCCI
90473 36591 NCCI
90473 36592 NCCI
90473 96160 NCCI
90473 96161 NCCI
90473 99201 NCCI
90473 99202 NCCI
90473 99203 NCCI
90473 99204 NCCI
90473 99205 NCCI
90473 99211 NCCI
90473 99212 NCCI
90473 99213 NCCI
90473 99214 NCCI
90473 99215 NCCI
90473 99241 NCCI
90473 99242 NCCI
90473 99243 NCCI
90473 99244 NCCI
90473 99245 NCCI
90473 99281 NCCI
90473 99282 NCCI
90473 99283 NCCI
90473 99284 NCCI
90473 99285 NCCI
90473 99381 NCCI
90473 99382 NCCI
90473 99383 NCCI
90473 99384 NCCI
90473 99385 NCCI
90473 99386 NCCI
90473 99387 NCCI
90473 99391 NCCI
90473 99392 NCCI
90473 99393 NCCI
90473 99394 NCCI
90473 99395 NCCI
90473 99396 NCCI
90473 99397 NCCI
90473 99401 NCCI
Comprehensive ComponentCode Code Source
90473 99402 NCCI
90473 99403 NCCI
90473 99404 NCCI
90473 99406 NCCI
90473 99407 NCCI
90473 99408 NCCI
90473 99409 NCCI
90473 99411 NCCI
90473 99412 NCCI
90473 99497 NCCI
90473 G0008 NCCI
90473 G0463 NCCI
90474 36591 NCCI
90474 36592 NCCI
90474 96160 NCCI
90474 96161 NCCI
90474 99201 NCCI
90474 99202 NCCI
90474 99203 NCCI
90474 99204 NCCI
90474 99205 NCCI
90474 99211 NCCI
90474 99212 NCCI
90474 99213 NCCI
90474 99214 NCCI
90474 99215 NCCI
90474 99241 NCCI
90474 99242 NCCI
90474 99243 NCCI
90474 99244 NCCI
90474 99245 NCCI
90474 99281 NCCI
90474 99282 NCCI
90474 99283 NCCI
90474 99284 NCCI
90474 99285 NCCI
90474 99381 NCCI
90474 99382 NCCI
90474 99383 NCCI
90474 99384 NCCI
90474 99385 NCCI
90474 99386 NCCI
90474 99387 NCCI
90474 99391 NCCI
90474 99392 NCCI
90474 99393 NCCI
90474 99394 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 4 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90474 99395 NCCI
90474 99396 NCCI
90474 99397 NCCI
90474 99401 NCCI
90474 99402 NCCI
90474 99403 NCCI
90474 99404 NCCI
90474 99406 NCCI
90474 99407 NCCI
90474 99408 NCCI
90474 99409 NCCI
90474 99411 NCCI
90474 99412 NCCI
90474 99497 NCCI
90474 G0463 NCCI
90476 36591 NCCI
90476 36592 NCCI
90476 90476 BCBST
90477 36591 NCCI
90477 36592 NCCI
90477 90477 BCBST
90581 36591 NCCI
90581 36592 NCCI
90581 90581 BCBST
90585 36591 NCCI
90585 36592 NCCI
90585 90585 BCBST
90585 90586 NCCI
90586 36591 NCCI
90586 36592 NCCI
90586 90586 BCBST
90586 J9031 BCBST
90620 36591 NCCI
90620 36592 NCCI
90620 90733 NCCI
90621 36591 NCCI
90621 36592 NCCI
90621 90620 NCCI
90621 90733 NCCI
90625 36591 NCCI
90625 36592 NCCI
90630 36591 NCCI
90630 36592 NCCI
90630 90653 NCCI
90630 90654 NCCI
90630 90655 NCCI
90630 90656 NCCI
Comprehensive ComponentCode Code Source
90630 90657 NCCI
90630 90658 NCCI
90630 90660 NCCI
90630 90661 NCCI
90630 90662 NCCI
90630 90664 NCCI
90630 90666 NCCI
90630 90667 NCCI
90630 90668 NCCI
90630 90672 NCCI
90630 90673 NCCI
90630 90674 NCCI
90630 90682 NCCI
90630 90685 NCCI
90630 90686 NCCI
90630 90687 NCCI
90630 90688 NCCI
90630 Q2034 NCCI
90630 Q2035 NCCI
90630 Q2036 NCCI
90630 Q2037 NCCI
90630 Q2038 NCCI
90630 Q2039 NCCI
90632 36591 NCCI
90632 36592 NCCI
90632 90632 BCBST
90632 90633 NCCI
90632 90634 NCCI
90633 36591 NCCI
90633 36592 NCCI
90633 90633 BCBST
90633 90634 NCCI
90633 90634 BCBST
90634 36591 NCCI
90634 36592 NCCI
90634 90634 BCBST
90636 36591 NCCI
90636 36592 NCCI
90636 90632 Reversed NCCI
90636 90633 Reversed NCCI
90636 90634 Reversed NCCI
90636 90636 BCBST
90636 90739 NCCI
90636 90740 BCBST
90636 90743 BCBST
90636 90744 BCBST
90636 90746 BCBST
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 5 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90636 90747 BCBST
90636 90748 BCBST
90636 G0010 BCBST
90644 36591 NCCI
90644 36592 NCCI
90645 90645 BCBST
90645 90646 Reversed NCCI
90645 90647 Reversed NCCI
90646 90646 BCBST
90646 90647 BCBST
90646 90648 BCBST
90647 36591 NCCI
90647 36592 NCCI
90647 90644 NCCI
90647 90647 BCBST
90647 90648 NCCI
90647 90648 BCBST
90647 90698 NCCI
90648 36591 NCCI
90648 36592 NCCI
90648 90644 NCCI
90648 90648 BCBST
90648 90698 NCCI
90649 36591 NCCI
90649 36592 NCCI
90649 90649 BCBST
90650 36591 NCCI
90650 36592 NCCI
90650 90649 NCCI
90651 36591 NCCI
90651 36592 NCCI
90651 90649 NCCI
90651 90650 NCCI
90653 36591 NCCI
90653 36592 NCCI
90653 Q2035 NCCI
90653 Q2036 NCCI
90653 Q2037 NCCI
90653 Q2038 NCCI
90653 Q2039 NCCI
90654 36591 NCCI
90654 36592 NCCI
90654 90653 NCCI
90654 90655 NCCI
90654 90656 NCCI
90654 90657 NCCI
90654 90658 NCCI
Comprehensive ComponentCode Code Source
90654 90660 NCCI
90654 90661 NCCI
90654 90662 NCCI
90654 90664 NCCI
90654 90666 NCCI
90654 90667 NCCI
90654 90668 NCCI
90654 90673 NCCI
90654 90674 NCCI
90654 90682 NCCI
90654 90685 NCCI
90654 90686 NCCI
90654 90687 NCCI
90654 90688 NCCI
90654 Q2034 NCCI
90655 36591 NCCI
90655 36592 NCCI
90655 90653 NCCI
90655 90655 BCBST
90655 90656 BCBST
90655 90657 NCCI
90655 90658 NCCI
90655 90660 NCCI
90655 90661 NCCI
90655 90662 NCCI
90655 90664 NCCI
90655 90666 NCCI
90655 90667 NCCI
90655 90668 NCCI
90655 Q2034 NCCI
90656 36591 NCCI
90656 36592 NCCI
90656 90653 NCCI
90656 90655 NCCI
90656 90656 BCBST
90656 90657 NCCI
90656 90658 NCCI
90656 90660 NCCI
90656 90661 NCCI
90656 90662 NCCI
90656 90664 NCCI
90656 90666 NCCI
90656 90667 NCCI
90656 90668 NCCI
90656 90673 NCCI
90656 90674 NCCI
90656 90682 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 6 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90656 90685 NCCI
90656 90686 NCCI
90656 90687 NCCI
90656 90688 NCCI
90656 Q2034 NCCI
90657 36591 NCCI
90657 36592 NCCI
90657 90653 NCCI
90657 90657 BCBST
90657 90658 NCCI
90657 90658 BCBST
90657 90660 NCCI
90657 90661 NCCI
90657 90662 NCCI
90657 90664 NCCI
90657 90666 NCCI
90657 90667 NCCI
90657 90668 NCCI
90658 36591 NCCI
90658 36592 NCCI
90658 90653 NCCI
90658 90658 BCBST
90658 90660 NCCI
90658 90661 NCCI
90658 90662 NCCI
90658 90664 NCCI
90658 90666 NCCI
90658 90667 NCCI
90658 90668 NCCI
90660 36591 NCCI
90660 36592 NCCI
90660 90653 NCCI
90660 90660 BCBST
90660 90661 NCCI
90660 90662 NCCI
90660 90664 NCCI
90660 90666 NCCI
90660 90667 NCCI
90660 90668 NCCI
90661 36591 NCCI
90661 36592 NCCI
90661 90653 NCCI
90661 90661 BCBST
90661 90662 NCCI
90661 90664 NCCI
90661 90666 NCCI
90661 90667 NCCI
Comprehensive ComponentCode Code Source
90661 90668 NCCI
90662 36591 NCCI
90662 36592 NCCI
90662 90653 NCCI
90662 90662 BCBST
90662 90664 NCCI
90662 90666 NCCI
90662 90667 NCCI
90662 90668 NCCI
90664 36591 NCCI
90664 36592 NCCI
90664 90653 NCCI
90664 90666 NCCI
90664 90667 NCCI
90664 90668 NCCI
90665 90665 BCBST
90666 36591 NCCI
90666 36592 NCCI
90666 90653 NCCI
90666 90667 NCCI
90666 90668 NCCI
90667 36591 NCCI
90667 36592 NCCI
90667 90653 NCCI
90667 90668 NCCI
90668 36591 NCCI
90668 36592 NCCI
90668 90653 NCCI
90669 90669 BCBST
90669 S0195 BCBST
90670 36591 NCCI
90670 36592 NCCI
90670 90732 NCCI
90672 36591 NCCI
90672 36592 NCCI
90672 90653 NCCI
90672 90654 NCCI
90672 90655 NCCI
90672 90656 NCCI
90672 90657 NCCI
90672 90658 NCCI
90672 90660 NCCI
90672 90661 NCCI
90672 90662 NCCI
90672 90664 NCCI
90672 90666 NCCI
90672 90667 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 7 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90672 90668 NCCI
90672 90673 NCCI
90672 90674 NCCI
90672 90682 NCCI
90672 90685 NCCI
90672 90686 NCCI
90672 90687 NCCI
90672 90688 NCCI
90672 Q2034 NCCI
90672 Q2035 NCCI
90672 Q2036 NCCI
90672 Q2037 NCCI
90672 Q2038 NCCI
90672 Q2039 NCCI
90673 36591 NCCI
90673 36592 NCCI
90673 90653 NCCI
90673 90655 NCCI
90673 90657 NCCI
90673 90658 NCCI
90673 90660 NCCI
90673 90661 NCCI
90673 90662 NCCI
90673 90664 NCCI
90673 90666 NCCI
90673 90667 NCCI
90673 90668 NCCI
90673 Q2034 NCCI
90674 36591 NCCI
90674 36592 NCCI
90674 90653 NCCI
90674 90655 NCCI
90674 90657 NCCI
90674 90658 NCCI
90674 90660 NCCI
90674 90661 NCCI
90674 90662 NCCI
90674 90664 NCCI
90674 90666 NCCI
90674 90667 NCCI
90674 90668 NCCI
90674 90673 NCCI
90674 90685 NCCI
90674 90686 NCCI
90674 90687 NCCI
90674 90688 NCCI
90674 96523 NCCI
Comprehensive ComponentCode Code Source
90674 Q2034 NCCI
90674 Q2035 NCCI
90674 Q2036 NCCI
90674 Q2037 NCCI
90674 Q2038 NCCI
90674 Q2039 NCCI
90675 36591 NCCI
90675 36592 NCCI
90675 90675 BCBST
90675 90676 NCCI
90676 36591 NCCI
90676 36592 NCCI
90676 90676 BCBST
90680 36591 NCCI
90680 36592 NCCI
90680 90680 BCBST
90681 36591 NCCI
90681 36592 NCCI
90681 90680 NCCI
90682 36591 NCCI
90682 36592 NCCI
90682 90653 NCCI
90682 90655 NCCI
90682 90657 NCCI
90682 90658 NCCI
90682 90660 NCCI
90682 90661 NCCI
90682 90662 NCCI
90682 90664 NCCI
90682 90666 NCCI
90682 90667 NCCI
90682 90668 NCCI
90682 90673 NCCI
90682 90685 NCCI
90682 90686 NCCI
90682 90687 NCCI
90682 90688 NCCI
90682 96523 NCCI
90682 Q2034 NCCI
90682 Q2035 NCCI
90682 Q2036 NCCI
90682 Q2037 NCCI
90682 Q2038 NCCI
90682 Q2039 NCCI
90685 36591 NCCI
90685 36592 NCCI
90685 90653 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 8 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90685 90655 NCCI
90685 90657 NCCI
90685 90658 NCCI
90685 90660 NCCI
90685 90661 NCCI
90685 90662 NCCI
90685 90664 NCCI
90685 90666 NCCI
90685 90667 NCCI
90685 90668 NCCI
90685 90673 NCCI
90685 90686 NCCI
90685 90687 NCCI
90685 90688 NCCI
90685 Q2034 NCCI
90686 36591 NCCI
90686 36592 NCCI
90686 90653 NCCI
90686 90655 NCCI
90686 90657 NCCI
90686 90658 NCCI
90686 90660 NCCI
90686 90661 NCCI
90686 90662 NCCI
90686 90664 NCCI
90686 90666 NCCI
90686 90667 NCCI
90686 90668 NCCI
90686 90673 NCCI
90686 90687 NCCI
90686 90688 NCCI
90686 Q2034 NCCI
90687 36591 NCCI
90687 36592 NCCI
90687 90653 NCCI
90687 90655 NCCI
90687 90657 NCCI
90687 90658 NCCI
90687 90660 NCCI
90687 90661 NCCI
90687 90662 NCCI
90687 90664 NCCI
90687 90666 NCCI
90687 90667 NCCI
90687 90668 NCCI
90687 90673 NCCI
90687 90688 NCCI
Comprehensive ComponentCode Code Source
90687 Q2034 NCCI
90688 36591 NCCI
90688 36592 NCCI
90688 90653 NCCI
90688 90655 NCCI
90688 90657 NCCI
90688 90658 NCCI
90688 90660 NCCI
90688 90661 NCCI
90688 90662 NCCI
90688 90664 NCCI
90688 90666 NCCI
90688 90667 NCCI
90688 90668 NCCI
90688 90673 NCCI
90688 Q2034 NCCI
90690 36591 NCCI
90690 36592 NCCI
90690 90690 BCBST
90691 36591 NCCI
90691 36592 NCCI
90691 90690 NCCI
90691 90691 BCBST
90691 90693 BCBST
90692 90692 BCBST
90693 90693 BCBST
90696 36591 NCCI
90696 36592 NCCI
90696 90698 NCCI
90696 90700 NCCI
90696 90702 NCCI
90696 90713 NCCI
90696 90714 NCCI
90696 90715 NCCI
90697 36591 NCCI
90697 36592 NCCI
90697 90647 NCCI
90697 90648 NCCI
90697 90696 NCCI
90697 90698 NCCI
90697 90700 NCCI
90697 90702 NCCI
90697 90713 NCCI
90697 90714 NCCI
90697 90715 NCCI
90697 90739 NCCI
90697 90740 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 9 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90697 90743 NCCI
90697 90744 NCCI
90697 90746 NCCI
90697 90747 NCCI
90697 90748 NCCI
90698 36591 NCCI
90698 36592 NCCI
90698 90645 BCBST
90698 90646 BCBST
90698 90647 BCBST
90698 90648 BCBST
90698 90698 BCBST
90698 90700 NCCI
90698 90702 NCCI
90698 90712 BCBST
90698 90713 BCBST
90698 90713 NCCI
90698 90714 NCCI
90698 90715 BCBST
90698 90720 BCBST
90698 90721 BCBST
90698 90723 BCBST
90698 90748 NCCI
90700 36591 NCCI
90700 36592 NCCI
90700 90700 BCBST
90700 90702 NCCI
90700 90714 BCBST
90700 90715 BCBST
90701 90701 BCBST
90701 90714 BCBST
90701 90715 BCBST
90702 36591 NCCI
90702 36592 NCCI
90702 90702 BCBST
90702 90714 BCBST
90703 90703 BCBST
90704 90704 BCBST
90705 90705 BCBST
90706 90706 BCBST
90707 36591 NCCI
90707 36592 NCCI
90707 90704 Reversed NCCI
90707 90705 Reversed NCCI
90707 90706 Reversed NCCI
90707 90707 BCBST
90707 90708 BCBST
Comprehensive ComponentCode Code Source
90708 90705 Reversed NCCI
90708 90706 Reversed NCCI
90708 90708 BCBST
90710 36591 NCCI
90710 36592 NCCI
90710 90704 Reversed NCCI
90710 90705 Reversed NCCI
90710 90706 Reversed NCCI
90710 90707 Reversed NCCI
90710 90708 Reversed NCCI
90710 90710 BCBST
90710 90716 NCCI
90712 90712 BCBST
90713 36591 NCCI
90713 36592 NCCI
90713 90713 BCBST
90714 36591 NCCI
90714 36592 NCCI
90714 90700 NCCI
90714 90702 NCCI
90714 90714 BCBST
90715 36591 NCCI
90715 36592 NCCI
90715 90698 NCCI
90715 90700 NCCI
90715 90702 NCCI
90715 90714 NCCI
90715 90715 BCBST
90716 36591 NCCI
90716 36592 NCCI
90716 90716 BCBST
90717 36591 NCCI
90717 36592 NCCI
90717 90717 BCBST
90718 90703 BCBST
90718 90718 BCBST
90719 90719 BCBST
90720 90645 Reversed NCCI
90720 90646 Reversed NCCI
90720 90647 Reversed NCCI
90720 90648 Reversed NCCI
90720 90700 Reversed NCCI
90720 90701 Reversed NCCI
90720 90702 Reversed NCCI
90720 90703 Reversed NCCI
90720 90718 Reversed NCCI
90720 90719 Reversed NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 10 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90720 90720 BCBST
90720 90721 BCBST
90721 90700 BCBST
90721 90719 Reversed NCCI
90721 90721 BCBST
90723 36591 NCCI
90723 36592 NCCI
90723 90700 BCBST
90723 90701 BCBST
90723 90702 BCBST
90723 90703 BCBST
90723 90712 BCBST
90723 90713 BCBST
90723 90714 BCBST
90723 90714 NCCI
90723 90715 BCBST
90723 90718 BCBST
90723 90719 BCBST
90723 90720 BCBST
90723 90721 BCBST
90723 90739 NCCI
90723 90744 BCBST
90723 90746 BCBST
90723 90747 BCBST
90723 90748 BCBST
90723 G0010 BCBST
90725 90725 BCBST
90727 90727 BCBST
90732 36591 NCCI
90732 36592 NCCI
90732 90732 BCBST
90732 S0195 BCBST
90733 36591 NCCI
90733 36592 NCCI
90733 90644 NCCI
90733 90733 BCBST
90733 90734 Reversed NCCI
90734 36591 NCCI
90734 36592 NCCI
90734 90644 NCCI
90734 90734 BCBST
90735 90735 BCBST
90736 36591 NCCI
90736 36592 NCCI
90736 90736 BCBST
90738 36591 NCCI
90738 36592 NCCI
Comprehensive ComponentCode Code Source
90739 36591 NCCI
90739 36592 NCCI
90740 36591 NCCI
90740 36592 NCCI
90740 90739 NCCI
90740 90747 NCCI
90743 36591 NCCI
90743 36592 NCCI
90743 90739 NCCI
90743 90740 NCCI
90743 90744 NCCI
90743 90746 NCCI
90743 90747 NCCI
90744 36591 NCCI
90744 36592 NCCI
90744 90739 NCCI
90744 90740 NCCI
90744 90744 BCBST
90744 90746 NCCI
90744 90747 NCCI
90746 36591 NCCI
90746 36592 NCCI
90746 90739 NCCI
90746 90740 NCCI
90746 90746 BCBST
90746 90747 NCCI
90747 36591 NCCI
90747 36592 NCCI
90747 90739 NCCI
90747 90747 BCBST
90748 36591 NCCI
90748 36592 NCCI
90748 90645 BCBST
90748 90646 BCBST
90748 90647 BCBST
90748 90648 BCBST
90748 90739 NCCI
90748 90740 BCBST
90748 90743 BCBST
90748 90744 BCBST
90748 90746 BCBST
90748 90747 BCBST
90748 90748 BCBST
90748 G0010 BCBST
90750 36591 NCCI
90750 36592 NCCI
90750 90736 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 11 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90750 96523 NCCI
90785 0359T NCCI
90785 0360T NCCI
90785 0361T NCCI
90785 0362T NCCI
90785 0363T NCCI
90785 0364T NCCI
90785 0365T NCCI
90785 0366T NCCI
90785 0367T NCCI
90785 0368T NCCI
90785 0369T NCCI
90785 0370T NCCI
90785 0371T NCCI
90785 0372T NCCI
90785 0373T NCCI
90785 0374T NCCI
90785 36591 NCCI
90785 36592 NCCI
90785 96150 NCCI
90785 96151 NCCI
90785 96152 NCCI
90785 96153 NCCI
90785 96154 NCCI
90785 96155 NCCI
90791 0359T NCCI
90791 0360T NCCI
90791 0361T NCCI
90791 0362T NCCI
90791 0363T NCCI
90791 0364T NCCI
90791 0365T NCCI
90791 0366T NCCI
90791 0367T NCCI
90791 0368T NCCI
90791 0369T NCCI
90791 0370T NCCI
90791 0371T NCCI
90791 0372T NCCI
90791 0373T NCCI
90791 0374T NCCI
90791 0405T NCCI
90791 36591 NCCI
90791 36592 NCCI
90791 90832 NCCI
90791 90833 NCCI
90791 90834 NCCI
Comprehensive ComponentCode Code Source
90791 90836 NCCI
90791 90837 NCCI
90791 90838 NCCI
90791 90839 NCCI
90791 90840 NCCI
90791 90845 NCCI
90791 90846 NCCI
90791 90847 NCCI
90791 90849 NCCI
90791 90853 NCCI
90791 90863 NCCI
90791 90865 NCCI
90791 90867 NCCI
90791 90868 NCCI
90791 90869 NCCI
90791 90870 NCCI
90791 90875 NCCI
90791 90876 NCCI
90791 90880 NCCI
90791 90882 NCCI
90791 90885 NCCI
90791 90887 NCCI
90791 90889 NCCI
90791 96116 NCCI
90791 96127 NCCI
90791 96150 NCCI
90791 96151 NCCI
90791 96152 NCCI
90791 96153 NCCI
90791 96154 NCCI
90791 96155 NCCI
90791 96160 NCCI
90791 96161 NCCI
90791 97802 NCCI
90791 97803 NCCI
90791 97804 NCCI
90791 99184 NCCI
90791 99201 NCCI
90791 99202 NCCI
90791 99203 NCCI
90791 99204 NCCI
90791 99205 NCCI
90791 99211 NCCI
90791 99212 NCCI
90791 99213 NCCI
90791 99214 NCCI
90791 99215 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 12 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90791 99217 NCCI
90791 99218 NCCI
90791 99219 NCCI
90791 99220 NCCI
90791 99221 NCCI
90791 99222 NCCI
90791 99223 NCCI
90791 99224 NCCI
90791 99225 NCCI
90791 99226 NCCI
90791 99231 NCCI
90791 99232 NCCI
90791 99233 NCCI
90791 99234 NCCI
90791 99235 NCCI
90791 99236 NCCI
90791 99238 NCCI
90791 99239 NCCI
90791 99241 NCCI
90791 99242 NCCI
90791 99243 NCCI
90791 99244 NCCI
90791 99245 NCCI
90791 99251 NCCI
90791 99252 NCCI
90791 99253 NCCI
90791 99254 NCCI
90791 99255 NCCI
90791 99281 NCCI
90791 99282 NCCI
90791 99283 NCCI
90791 99284 NCCI
90791 99285 NCCI
90791 99288 NCCI
90791 99291 NCCI
90791 99292 NCCI
90791 99304 NCCI
90791 99305 NCCI
90791 99306 NCCI
90791 99307 NCCI
90791 99308 NCCI
90791 99309 NCCI
90791 99310 NCCI
90791 99315 NCCI
90791 99316 NCCI
90791 99318 NCCI
90791 99324 NCCI
Comprehensive ComponentCode Code Source
90791 99325 NCCI
90791 99326 NCCI
90791 99327 NCCI
90791 99328 NCCI
90791 99334 NCCI
90791 99335 NCCI
90791 99336 NCCI
90791 99337 NCCI
90791 99339 NCCI
90791 99340 NCCI
90791 99341 NCCI
90791 99342 NCCI
90791 99343 NCCI
90791 99344 NCCI
90791 99345 NCCI
90791 99347 NCCI
90791 99348 NCCI
90791 99349 NCCI
90791 99350 NCCI
90791 99354 NCCI
90791 99355 NCCI
90791 99356 NCCI
90791 99357 NCCI
90791 99358 NCCI
90791 99359 NCCI
90791 99360 NCCI
90791 99363 NCCI
90791 99364 NCCI
90791 99366 NCCI
90791 99367 NCCI
90791 99368 NCCI
90791 99374 NCCI
90791 99375 NCCI
90791 99377 NCCI
90791 99378 NCCI
90791 99379 NCCI
90791 99380 NCCI
90791 99381 NCCI
90791 99382 NCCI
90791 99383 NCCI
90791 99384 NCCI
90791 99385 NCCI
90791 99386 NCCI
90791 99387 NCCI
90791 99391 NCCI
90791 99392 NCCI
90791 99393 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 13 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90791 99394 NCCI
90791 99395 NCCI
90791 99396 NCCI
90791 99397 NCCI
90791 99401 NCCI
90791 99402 NCCI
90791 99403 NCCI
90791 99404 NCCI
90791 99406 NCCI
90791 99407 NCCI
90791 99408 NCCI
90791 99409 NCCI
90791 99411 NCCI
90791 99412 NCCI
90791 99415 NCCI
90791 99416 NCCI
90791 99441 NCCI
90791 99442 NCCI
90791 99443 NCCI
90791 99444 NCCI
90791 99446 NCCI
90791 99447 NCCI
90791 99448 NCCI
90791 99449 NCCI
90791 99450 NCCI
90791 99455 NCCI
90791 99456 NCCI
90791 99460 NCCI
90791 99461 NCCI
90791 99462 NCCI
90791 99463 NCCI
90791 99464 NCCI
90791 99465 NCCI
90791 99466 NCCI
90791 99467 NCCI
90791 99468 NCCI
90791 99469 NCCI
90791 99471 NCCI
90791 99472 NCCI
90791 99475 NCCI
90791 99476 NCCI
90791 99477 NCCI
90791 99478 NCCI
90791 99479 NCCI
90791 99480 NCCI
90791 99485 NCCI
90791 99486 NCCI
Comprehensive ComponentCode Code Source
90791 99487 NCCI
90791 99489 NCCI
90791 99490 NCCI
90791 99495 NCCI
90791 99496 NCCI
90791 99497 NCCI
90791 99605 NCCI
90791 99606 NCCI
90791 G0270 NCCI
90791 G0271 NCCI
90791 G0380 NCCI
90791 G0381 NCCI
90791 G0382 NCCI
90791 G0383 NCCI
90791 G0384 NCCI
90791 G0396 NCCI
90791 G0397 NCCI
90791 G0406 NCCI
90791 G0407 NCCI
90791 G0408 NCCI
90791 G0409 NCCI
90791 G0410 NCCI
90791 G0411 NCCI
90791 G0425 NCCI
90791 G0426 NCCI
90791 G0427 NCCI
90791 G0442 NCCI
90791 G0443 NCCI
90791 G0444 NCCI
90791 G0445 NCCI
90791 G0446 NCCI
90791 G0447 NCCI
90791 G0459 NCCI
90791 G0463 NCCI
90791 G0473 NCCI
90792 0359T NCCI
90792 0360T NCCI
90792 0361T NCCI
90792 0362T NCCI
90792 0363T NCCI
90792 0364T NCCI
90792 0365T NCCI
90792 0366T NCCI
90792 0367T NCCI
90792 0368T NCCI
90792 0369T NCCI
90792 0370T NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 14 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90792 0371T NCCI
90792 0372T NCCI
90792 0373T NCCI
90792 0374T NCCI
90792 0405T NCCI
90792 36591 NCCI
90792 36592 NCCI
90792 90791 NCCI
90792 90832 NCCI
90792 90833 NCCI
90792 90834 NCCI
90792 90836 NCCI
90792 90837 NCCI
90792 90838 NCCI
90792 90839 NCCI
90792 90840 NCCI
90792 90845 NCCI
90792 90846 NCCI
90792 90847 NCCI
90792 90849 NCCI
90792 90853 NCCI
90792 90863 NCCI
90792 90865 NCCI
90792 90867 NCCI
90792 90868 NCCI
90792 90869 NCCI
90792 90870 NCCI
90792 90875 NCCI
90792 90876 NCCI
90792 90880 NCCI
90792 90882 NCCI
90792 90885 NCCI
90792 90887 NCCI
90792 90889 NCCI
90792 96116 NCCI
90792 96127 NCCI
90792 96150 NCCI
90792 96151 NCCI
90792 96152 NCCI
90792 96153 NCCI
90792 96154 NCCI
90792 96155 NCCI
90792 96160 NCCI
90792 96161 NCCI
90792 97802 NCCI
90792 97803 NCCI
90792 97804 NCCI
Comprehensive ComponentCode Code Source
90792 99184 NCCI
90792 99201 NCCI
90792 99202 NCCI
90792 99203 NCCI
90792 99204 NCCI
90792 99205 NCCI
90792 99211 NCCI
90792 99212 NCCI
90792 99213 NCCI
90792 99214 NCCI
90792 99215 NCCI
90792 99217 NCCI
90792 99218 NCCI
90792 99219 NCCI
90792 99220 NCCI
90792 99221 NCCI
90792 99222 NCCI
90792 99223 NCCI
90792 99224 NCCI
90792 99225 NCCI
90792 99226 NCCI
90792 99231 NCCI
90792 99232 NCCI
90792 99233 NCCI
90792 99234 NCCI
90792 99235 NCCI
90792 99236 NCCI
90792 99238 NCCI
90792 99239 NCCI
90792 99241 NCCI
90792 99242 NCCI
90792 99243 NCCI
90792 99244 NCCI
90792 99245 NCCI
90792 99251 NCCI
90792 99252 NCCI
90792 99253 NCCI
90792 99254 NCCI
90792 99255 NCCI
90792 99281 NCCI
90792 99282 NCCI
90792 99283 NCCI
90792 99284 NCCI
90792 99285 NCCI
90792 99288 NCCI
90792 99291 NCCI
90792 99292 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 15 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90792 99304 NCCI
90792 99305 NCCI
90792 99306 NCCI
90792 99307 NCCI
90792 99308 NCCI
90792 99309 NCCI
90792 99310 NCCI
90792 99315 NCCI
90792 99316 NCCI
90792 99318 NCCI
90792 99324 NCCI
90792 99325 NCCI
90792 99326 NCCI
90792 99327 NCCI
90792 99328 NCCI
90792 99334 NCCI
90792 99335 NCCI
90792 99336 NCCI
90792 99337 NCCI
90792 99339 NCCI
90792 99340 NCCI
90792 99341 NCCI
90792 99342 NCCI
90792 99343 NCCI
90792 99344 NCCI
90792 99345 NCCI
90792 99347 NCCI
90792 99348 NCCI
90792 99349 NCCI
90792 99350 NCCI
90792 99354 NCCI
90792 99355 NCCI
90792 99356 NCCI
90792 99357 NCCI
90792 99358 NCCI
90792 99359 NCCI
90792 99360 NCCI
90792 99363 NCCI
90792 99364 NCCI
90792 99366 NCCI
90792 99367 NCCI
90792 99368 NCCI
90792 99374 NCCI
90792 99375 NCCI
90792 99377 NCCI
90792 99378 NCCI
90792 99379 NCCI
Comprehensive ComponentCode Code Source
90792 99380 NCCI
90792 99381 NCCI
90792 99382 NCCI
90792 99383 NCCI
90792 99384 NCCI
90792 99385 NCCI
90792 99386 NCCI
90792 99387 NCCI
90792 99391 NCCI
90792 99392 NCCI
90792 99393 NCCI
90792 99394 NCCI
90792 99395 NCCI
90792 99396 NCCI
90792 99397 NCCI
90792 99401 NCCI
90792 99402 NCCI
90792 99403 NCCI
90792 99404 NCCI
90792 99406 NCCI
90792 99407 NCCI
90792 99408 NCCI
90792 99409 NCCI
90792 99411 NCCI
90792 99412 NCCI
90792 99415 NCCI
90792 99416 NCCI
90792 99441 NCCI
90792 99442 NCCI
90792 99443 NCCI
90792 99444 NCCI
90792 99446 NCCI
90792 99447 NCCI
90792 99448 NCCI
90792 99449 NCCI
90792 99450 NCCI
90792 99455 NCCI
90792 99456 NCCI
90792 99460 NCCI
90792 99461 NCCI
90792 99462 NCCI
90792 99463 NCCI
90792 99464 NCCI
90792 99465 NCCI
90792 99466 NCCI
90792 99467 NCCI
90792 99468 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 16 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90792 99469 NCCI
90792 99471 NCCI
90792 99472 NCCI
90792 99475 NCCI
90792 99476 NCCI
90792 99477 NCCI
90792 99478 NCCI
90792 99479 NCCI
90792 99480 NCCI
90792 99485 NCCI
90792 99486 NCCI
90792 99487 NCCI
90792 99489 NCCI
90792 99490 NCCI
90792 99495 NCCI
90792 99496 NCCI
90792 99497 NCCI
90792 99605 NCCI
90792 99606 NCCI
90792 G0270 NCCI
90792 G0271 NCCI
90792 G0380 NCCI
90792 G0381 NCCI
90792 G0382 NCCI
90792 G0383 NCCI
90792 G0384 NCCI
90792 G0396 NCCI
90792 G0397 NCCI
90792 G0406 NCCI
90792 G0407 NCCI
90792 G0408 NCCI
90792 G0409 NCCI
90792 G0410 NCCI
90792 G0411 NCCI
90792 G0425 NCCI
90792 G0426 NCCI
90792 G0427 NCCI
90792 G0442 NCCI
90792 G0443 NCCI
90792 G0444 NCCI
90792 G0445 NCCI
90792 G0446 NCCI
90792 G0447 NCCI
90792 G0459 NCCI
90792 G0463 NCCI
90792 G0473 NCCI
90801 99241 Retained NCCI
Comprehensive ComponentCode Code Source
90801 99242 Retained NCCI
90801 99243 Retained NCCI
90801 99244 Retained NCCI
90801 99245 Retained NCCI
90801 99251 Retained NCCI
90801 99252 Retained NCCI
90801 99253 Retained NCCI
90801 99254 Retained NCCI
90801 99255 Retained NCCI
90802 90802 BCBST
90802 99241 Retained NCCI
90802 99242 Retained NCCI
90802 99243 Retained NCCI
90802 99244 Retained NCCI
90802 99245 Retained NCCI
90802 99251 Retained NCCI
90802 99252 Retained NCCI
90802 99253 Retained NCCI
90802 99254 Retained NCCI
90802 99255 Retained NCCI
90804 90804 BCBST
90804 99251 Retained NCCI
90804 99252 Retained NCCI
90804 99253 Retained NCCI
90804 99254 Retained NCCI
90804 99255 Retained NCCI
90805 90805 BCBST
90805 99241 Retained NCCI
90805 99242 Retained NCCI
90805 99243 Retained NCCI
90805 99244 Retained NCCI
90805 99245 Retained NCCI
90805 99251 Retained NCCI
90805 99252 Retained NCCI
90805 99253 Retained NCCI
90805 99254 Retained NCCI
90805 99255 Retained NCCI
90806 90806 BCBST
90806 99251 Retained NCCI
90806 99252 Retained NCCI
90806 99253 Retained NCCI
90806 99254 Retained NCCI
90806 99255 Retained NCCI
90807 90807 BCBST
90807 99241 Retained NCCI
90807 99242 Retained NCCI
90807 99243 Retained NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 17 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90807 99244 Retained NCCI
90807 99245 Retained NCCI
90807 99251 Retained NCCI
90807 99252 Retained NCCI
90807 99253 Retained NCCI
90807 99254 Retained NCCI
90807 99255 Retained NCCI
90808 90808 BCBST
90808 99251 Retained NCCI
90808 99252 Retained NCCI
90808 99253 Retained NCCI
90808 99254 Retained NCCI
90808 99255 Retained NCCI
90809 90809 BCBST
90809 99241 Retained NCCI
90809 99242 Retained NCCI
90809 99243 Retained NCCI
90809 99244 Retained NCCI
90809 99245 Retained NCCI
90809 99251 Retained NCCI
90809 99252 Retained NCCI
90809 99253 Retained NCCI
90809 99254 Retained NCCI
90809 99255 Retained NCCI
90810 90810 BCBST
90810 99251 Retained NCCI
90810 99252 Retained NCCI
90810 99253 Retained NCCI
90810 99254 Retained NCCI
90810 99255 Retained NCCI
90811 90811 BCBST
90811 99241 Retained NCCI
90811 99242 Retained NCCI
90811 99243 Retained NCCI
90811 99244 Retained NCCI
90811 99245 Retained NCCI
90811 99251 Retained NCCI
90811 99252 Retained NCCI
90811 99253 Retained NCCI
90811 99254 Retained NCCI
90811 99255 Retained NCCI
90812 90812 BCBST
90812 99251 Retained NCCI
90812 99252 Retained NCCI
90812 99253 Retained NCCI
90812 99254 Retained NCCI
90812 99255 Retained NCCI
Comprehensive ComponentCode Code Source
90813 90813 BCBST
90813 99241 Retained NCCI
90813 99242 Retained NCCI
90813 99243 Retained NCCI
90813 99244 Retained NCCI
90813 99245 Retained NCCI
90813 99251 Retained NCCI
90813 99252 Retained NCCI
90813 99253 Retained NCCI
90813 99254 Retained NCCI
90813 99255 Retained NCCI
90814 90814 BCBST
90814 99251 Retained NCCI
90814 99252 Retained NCCI
90814 99253 Retained NCCI
90814 99254 Retained NCCI
90814 99255 Retained NCCI
90815 90815 BCBST
90815 99241 Retained NCCI
90815 99242 Retained NCCI
90815 99243 Retained NCCI
90815 99244 Retained NCCI
90815 99245 Retained NCCI
90815 99251 Retained NCCI
90815 99252 Retained NCCI
90815 99253 Retained NCCI
90815 99254 Retained NCCI
90815 99255 Retained NCCI
90816 90816 BCBST
90816 99241 Retained NCCI
90816 99242 Retained NCCI
90816 99243 Retained NCCI
90816 99244 Retained NCCI
90816 99245 Retained NCCI
90817 90817 BCBST
90817 99241 Retained NCCI
90817 99242 Retained NCCI
90817 99243 Retained NCCI
90817 99244 Retained NCCI
90817 99245 Retained NCCI
90817 99251 Retained NCCI
90817 99252 Retained NCCI
90817 99253 Retained NCCI
90817 99254 Retained NCCI
90817 99255 Retained NCCI
90818 90818 BCBST
90818 99241 Retained NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 18 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90818 99242 Retained NCCI
90818 99243 Retained NCCI
90818 99244 Retained NCCI
90818 99245 Retained NCCI
90819 90819 BCBST
90819 99241 Retained NCCI
90819 99242 Retained NCCI
90819 99243 Retained NCCI
90819 99244 Retained NCCI
90819 99245 Retained NCCI
90819 99251 Retained NCCI
90819 99252 Retained NCCI
90819 99253 Retained NCCI
90819 99254 Retained NCCI
90819 99255 Retained NCCI
90821 90821 BCBST
90821 99241 Retained NCCI
90821 99242 Retained NCCI
90821 99243 Retained NCCI
90821 99244 Retained NCCI
90821 99245 Retained NCCI
90822 90822 BCBST
90822 99241 Retained NCCI
90822 99242 Retained NCCI
90822 99243 Retained NCCI
90822 99244 Retained NCCI
90822 99245 Retained NCCI
90822 99251 Retained NCCI
90822 99252 Retained NCCI
90822 99253 Retained NCCI
90822 99254 Retained NCCI
90822 99255 Retained NCCI
90823 90823 BCBST
90823 99241 Retained NCCI
90823 99242 Retained NCCI
90823 99243 Retained NCCI
90823 99244 Retained NCCI
90823 99245 Retained NCCI
90824 90824 BCBST
90824 99241 Retained NCCI
90824 99242 Retained NCCI
90824 99243 Retained NCCI
90824 99244 Retained NCCI
90824 99245 Retained NCCI
90824 99251 Retained NCCI
90824 99252 Retained NCCI
90824 99253 Retained NCCI
Comprehensive ComponentCode Code Source
90824 99254 Retained NCCI
90824 99255 Retained NCCI
90826 90826 BCBST
90826 99241 Retained NCCI
90826 99242 Retained NCCI
90826 99243 Retained NCCI
90826 99244 Retained NCCI
90826 99245 Retained NCCI
90827 99241 Retained NCCI
90827 99242 Retained NCCI
90827 99243 Retained NCCI
90827 99244 Retained NCCI
90827 99245 Retained NCCI
90827 99251 Retained NCCI
90827 99252 Retained NCCI
90827 99253 Retained NCCI
90827 99254 Retained NCCI
90827 99255 Retained NCCI
90828 90828 BCBST
90828 99241 Retained NCCI
90828 99242 Retained NCCI
90828 99243 Retained NCCI
90828 99244 Retained NCCI
90828 99245 Retained NCCI
90829 90829 BCBST
90829 99241 Retained NCCI
90829 99242 Retained NCCI
90829 99243 Retained NCCI
90829 99244 Retained NCCI
90829 99245 Retained NCCI
90829 99251 Retained NCCI
90829 99252 Retained NCCI
90829 99253 Retained NCCI
90829 99254 Retained NCCI
90829 99255 Retained NCCI
90832 0359T NCCI
90832 0360T NCCI
90832 0361T NCCI
90832 0362T NCCI
90832 0363T NCCI
90832 0364T NCCI
90832 0365T NCCI
90832 0366T NCCI
90832 0367T NCCI
90832 0368T NCCI
90832 0369T NCCI
90832 0370T NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 19 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90832 0371T NCCI
90832 0372T NCCI
90832 0373T NCCI
90832 0374T NCCI
90832 0405T NCCI
90832 36591 NCCI
90832 36592 NCCI
90832 36640 NCCI
90832 90839 NCCI
90832 90840 NCCI
90832 90867 NCCI
90832 90868 NCCI
90832 90869 NCCI
90832 96116 NCCI
90832 96127 NCCI
90832 96150 NCCI
90832 96151 NCCI
90832 96152 NCCI
90832 96153 NCCI
90832 96154 NCCI
90832 96155 NCCI
90832 96160 NCCI
90832 96161 NCCI
90832 97802 NCCI
90832 97803 NCCI
90832 97804 NCCI
90832 99184 NCCI
90832 99201 NCCI
90832 99202 NCCI
90832 99203 NCCI
90832 99204 NCCI
90832 99205 NCCI
90832 99211 NCCI
90832 99212 NCCI
90832 99213 NCCI
90832 99214 NCCI
90832 99215 NCCI
90832 99217 NCCI
90832 99218 NCCI
90832 99219 NCCI
90832 99220 NCCI
90832 99221 NCCI
90832 99222 NCCI
90832 99223 NCCI
90832 99224 NCCI
90832 99225 NCCI
90832 99226 NCCI
Comprehensive ComponentCode Code Source
90832 99231 NCCI
90832 99232 NCCI
90832 99233 NCCI
90832 99234 NCCI
90832 99235 NCCI
90832 99236 NCCI
90832 99238 NCCI
90832 99239 NCCI
90832 99241 NCCI
90832 99242 NCCI
90832 99243 NCCI
90832 99244 NCCI
90832 99245 NCCI
90832 99251 NCCI
90832 99252 NCCI
90832 99253 NCCI
90832 99254 NCCI
90832 99255 NCCI
90832 99281 NCCI
90832 99282 NCCI
90832 99283 NCCI
90832 99284 NCCI
90832 99285 NCCI
90832 99288 NCCI
90832 99291 NCCI
90832 99292 NCCI
90832 99304 NCCI
90832 99305 NCCI
90832 99306 NCCI
90832 99307 NCCI
90832 99308 NCCI
90832 99309 NCCI
90832 99310 NCCI
90832 99315 NCCI
90832 99316 NCCI
90832 99318 NCCI
90832 99324 NCCI
90832 99325 NCCI
90832 99326 NCCI
90832 99327 NCCI
90832 99328 NCCI
90832 99334 NCCI
90832 99335 NCCI
90832 99336 NCCI
90832 99337 NCCI
90832 99339 NCCI
90832 99340 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 20 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90832 99341 NCCI
90832 99342 NCCI
90832 99343 NCCI
90832 99344 NCCI
90832 99345 NCCI
90832 99347 NCCI
90832 99348 NCCI
90832 99349 NCCI
90832 99350 NCCI
90832 99354 NCCI
90832 99355 NCCI
90832 99356 NCCI
90832 99357 NCCI
90832 99358 NCCI
90832 99359 NCCI
90832 99360 NCCI
90832 99363 NCCI
90832 99364 NCCI
90832 99366 NCCI
90832 99367 NCCI
90832 99368 NCCI
90832 99374 NCCI
90832 99375 NCCI
90832 99377 NCCI
90832 99378 NCCI
90832 99379 NCCI
90832 99380 NCCI
90832 99381 NCCI
90832 99382 NCCI
90832 99383 NCCI
90832 99384 NCCI
90832 99385 NCCI
90832 99386 NCCI
90832 99387 NCCI
90832 99391 NCCI
90832 99392 NCCI
90832 99393 NCCI
90832 99394 NCCI
90832 99395 NCCI
90832 99396 NCCI
90832 99397 NCCI
90832 99401 NCCI
90832 99402 NCCI
90832 99403 NCCI
90832 99404 NCCI
90832 99406 NCCI
90832 99407 NCCI
Comprehensive ComponentCode Code Source
90832 99408 NCCI
90832 99409 NCCI
90832 99411 NCCI
90832 99412 NCCI
90832 99415 NCCI
90832 99416 NCCI
90832 99429 NCCI
90832 99441 NCCI
90832 99442 NCCI
90832 99443 NCCI
90832 99444 NCCI
90832 99446 NCCI
90832 99447 NCCI
90832 99448 NCCI
90832 99449 NCCI
90832 99450 NCCI
90832 99455 NCCI
90832 99456 NCCI
90832 99460 NCCI
90832 99461 NCCI
90832 99462 NCCI
90832 99463 NCCI
90832 99464 NCCI
90832 99465 NCCI
90832 99466 NCCI
90832 99467 NCCI
90832 99468 NCCI
90832 99469 NCCI
90832 99471 NCCI
90832 99472 NCCI
90832 99475 NCCI
90832 99476 NCCI
90832 99477 NCCI
90832 99478 NCCI
90832 99479 NCCI
90832 99480 NCCI
90832 99485 NCCI
90832 99486 NCCI
90832 99487 NCCI
90832 99489 NCCI
90832 99490 NCCI
90832 99495 NCCI
90832 99496 NCCI
90832 99497 NCCI
90832 99605 NCCI
90832 99606 NCCI
90832 G0176 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 21 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90832 G0177 NCCI
90832 G0270 NCCI
90832 G0271 NCCI
90832 G0380 NCCI
90832 G0381 NCCI
90832 G0382 NCCI
90832 G0383 NCCI
90832 G0384 NCCI
90832 G0396 NCCI
90832 G0397 NCCI
90832 G0406 NCCI
90832 G0407 NCCI
90832 G0409 NCCI
90832 G0410 NCCI
90832 G0411 NCCI
90832 G0442 NCCI
90832 G0443 NCCI
90832 G0444 NCCI
90832 G0445 NCCI
90832 G0446 NCCI
90832 G0447 NCCI
90832 G0459 NCCI
90832 G0463 NCCI
90832 G0473 NCCI
90833 0359T NCCI
90833 0360T NCCI
90833 0361T NCCI
90833 0362T NCCI
90833 0363T NCCI
90833 0364T NCCI
90833 0365T NCCI
90833 0366T NCCI
90833 0367T NCCI
90833 0368T NCCI
90833 0369T NCCI
90833 0370T NCCI
90833 0371T NCCI
90833 0372T NCCI
90833 0373T NCCI
90833 0374T NCCI
90833 0405T NCCI
90833 36591 NCCI
90833 36592 NCCI
90833 36640 NCCI
90833 90832 NCCI
90833 90839 NCCI
90833 90840 NCCI
Comprehensive ComponentCode Code Source
90833 90867 NCCI
90833 90868 NCCI
90833 90869 NCCI
90833 96116 NCCI
90833 96127 NCCI
90833 96150 NCCI
90833 96151 NCCI
90833 96152 NCCI
90833 96153 NCCI
90833 96154 NCCI
90833 96155 NCCI
90833 96160 NCCI
90833 96161 NCCI
90833 97802 NCCI
90833 97803 NCCI
90833 97804 NCCI
90833 99184 NCCI
90833 99281 NCCI
90833 99282 NCCI
90833 99283 NCCI
90833 99284 NCCI
90833 99285 NCCI
90833 99288 NCCI
90833 99291 NCCI
90833 99292 NCCI
90833 99339 NCCI
90833 99340 NCCI
90833 99354 NCCI
90833 99355 NCCI
90833 99356 NCCI
90833 99357 NCCI
90833 99358 NCCI
90833 99359 NCCI
90833 99360 NCCI
90833 99363 NCCI
90833 99364 NCCI
90833 99366 NCCI
90833 99367 NCCI
90833 99368 NCCI
90833 99374 NCCI
90833 99375 NCCI
90833 99377 NCCI
90833 99378 NCCI
90833 99379 NCCI
90833 99380 NCCI
90833 99381 NCCI
90833 99382 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 22 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90833 99383 NCCI
90833 99384 NCCI
90833 99385 NCCI
90833 99386 NCCI
90833 99387 NCCI
90833 99391 NCCI
90833 99392 NCCI
90833 99393 NCCI
90833 99394 NCCI
90833 99395 NCCI
90833 99396 NCCI
90833 99397 NCCI
90833 99401 NCCI
90833 99402 NCCI
90833 99403 NCCI
90833 99404 NCCI
90833 99406 NCCI
90833 99407 NCCI
90833 99408 NCCI
90833 99409 NCCI
90833 99411 NCCI
90833 99412 NCCI
90833 99415 NCCI
90833 99416 NCCI
90833 99429 NCCI
90833 99441 NCCI
90833 99442 NCCI
90833 99443 NCCI
90833 99444 NCCI
90833 99446 NCCI
90833 99447 NCCI
90833 99448 NCCI
90833 99449 NCCI
90833 99450 NCCI
90833 99455 NCCI
90833 99456 NCCI
90833 99460 NCCI
90833 99461 NCCI
90833 99462 NCCI
90833 99463 NCCI
90833 99464 NCCI
90833 99465 NCCI
90833 99466 NCCI
90833 99467 NCCI
90833 99468 NCCI
90833 99469 NCCI
90833 99471 NCCI
Comprehensive ComponentCode Code Source
90833 99472 NCCI
90833 99475 NCCI
90833 99476 NCCI
90833 99477 NCCI
90833 99478 NCCI
90833 99479 NCCI
90833 99480 NCCI
90833 99485 NCCI
90833 99486 NCCI
90833 99487 NCCI
90833 99489 NCCI
90833 99490 NCCI
90833 99495 NCCI
90833 99496 NCCI
90833 99605 NCCI
90833 99606 NCCI
90833 G0176 NCCI
90833 G0177 NCCI
90833 G0270 NCCI
90833 G0271 NCCI
90833 G0380 NCCI
90833 G0381 NCCI
90833 G0382 NCCI
90833 G0383 NCCI
90833 G0384 NCCI
90833 G0396 NCCI
90833 G0397 NCCI
90833 G0406 NCCI
90833 G0409 NCCI
90833 G0410 NCCI
90833 G0411 NCCI
90833 G0442 NCCI
90833 G0443 NCCI
90833 G0444 NCCI
90833 G0445 NCCI
90833 G0446 NCCI
90833 G0447 NCCI
90833 G0459 NCCI
90833 G0473 NCCI
90834 0359T NCCI
90834 0360T NCCI
90834 0361T NCCI
90834 0362T NCCI
90834 0363T NCCI
90834 0364T NCCI
90834 0365T NCCI
90834 0366T NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 23 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90834 0367T NCCI
90834 0368T NCCI
90834 0369T NCCI
90834 0370T NCCI
90834 0371T NCCI
90834 0372T NCCI
90834 0373T NCCI
90834 0374T NCCI
90834 0405T NCCI
90834 36591 NCCI
90834 36592 NCCI
90834 36640 NCCI
90834 90832 NCCI
90834 90833 NCCI
90834 90839 NCCI
90834 90840 NCCI
90834 90845 NCCI
90834 90867 NCCI
90834 90868 NCCI
90834 90869 NCCI
90834 96116 NCCI
90834 96127 NCCI
90834 96150 NCCI
90834 96151 NCCI
90834 96152 NCCI
90834 96153 NCCI
90834 96154 NCCI
90834 96155 NCCI
90834 96160 NCCI
90834 96161 NCCI
90834 97802 NCCI
90834 97803 NCCI
90834 97804 NCCI
90834 99184 NCCI
90834 99201 NCCI
90834 99202 NCCI
90834 99203 NCCI
90834 99204 NCCI
90834 99205 NCCI
90834 99211 NCCI
90834 99212 NCCI
90834 99213 NCCI
90834 99214 NCCI
90834 99215 NCCI
90834 99217 NCCI
90834 99218 NCCI
90834 99219 NCCI
Comprehensive ComponentCode Code Source
90834 99220 NCCI
90834 99221 NCCI
90834 99222 NCCI
90834 99223 NCCI
90834 99224 NCCI
90834 99225 NCCI
90834 99226 NCCI
90834 99231 NCCI
90834 99232 NCCI
90834 99233 NCCI
90834 99234 NCCI
90834 99235 NCCI
90834 99236 NCCI
90834 99238 NCCI
90834 99239 NCCI
90834 99241 NCCI
90834 99242 NCCI
90834 99243 NCCI
90834 99244 NCCI
90834 99245 NCCI
90834 99251 NCCI
90834 99252 NCCI
90834 99253 NCCI
90834 99254 NCCI
90834 99255 NCCI
90834 99281 NCCI
90834 99282 NCCI
90834 99283 NCCI
90834 99284 NCCI
90834 99285 NCCI
90834 99288 NCCI
90834 99291 NCCI
90834 99292 NCCI
90834 99304 NCCI
90834 99305 NCCI
90834 99306 NCCI
90834 99307 NCCI
90834 99308 NCCI
90834 99309 NCCI
90834 99310 NCCI
90834 99315 NCCI
90834 99316 NCCI
90834 99318 NCCI
90834 99324 NCCI
90834 99325 NCCI
90834 99326 NCCI
90834 99327 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 24 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90834 99328 NCCI
90834 99334 NCCI
90834 99335 NCCI
90834 99336 NCCI
90834 99337 NCCI
90834 99339 NCCI
90834 99340 NCCI
90834 99341 NCCI
90834 99342 NCCI
90834 99343 NCCI
90834 99344 NCCI
90834 99345 NCCI
90834 99347 NCCI
90834 99348 NCCI
90834 99349 NCCI
90834 99350 NCCI
90834 99354 NCCI
90834 99355 NCCI
90834 99356 NCCI
90834 99357 NCCI
90834 99358 NCCI
90834 99359 NCCI
90834 99360 NCCI
90834 99363 NCCI
90834 99364 NCCI
90834 99366 NCCI
90834 99367 NCCI
90834 99368 NCCI
90834 99374 NCCI
90834 99375 NCCI
90834 99377 NCCI
90834 99378 NCCI
90834 99379 NCCI
90834 99380 NCCI
90834 99381 NCCI
90834 99382 NCCI
90834 99383 NCCI
90834 99384 NCCI
90834 99385 NCCI
90834 99386 NCCI
90834 99387 NCCI
90834 99391 NCCI
90834 99392 NCCI
90834 99393 NCCI
90834 99394 NCCI
90834 99395 NCCI
90834 99396 NCCI
Comprehensive ComponentCode Code Source
90834 99397 NCCI
90834 99401 NCCI
90834 99402 NCCI
90834 99403 NCCI
90834 99404 NCCI
90834 99406 NCCI
90834 99407 NCCI
90834 99408 NCCI
90834 99409 NCCI
90834 99411 NCCI
90834 99412 NCCI
90834 99415 NCCI
90834 99416 NCCI
90834 99429 NCCI
90834 99441 NCCI
90834 99442 NCCI
90834 99443 NCCI
90834 99444 NCCI
90834 99446 NCCI
90834 99447 NCCI
90834 99448 NCCI
90834 99449 NCCI
90834 99450 NCCI
90834 99455 NCCI
90834 99456 NCCI
90834 99460 NCCI
90834 99461 NCCI
90834 99462 NCCI
90834 99463 NCCI
90834 99464 NCCI
90834 99465 NCCI
90834 99466 NCCI
90834 99467 NCCI
90834 99468 NCCI
90834 99469 NCCI
90834 99471 NCCI
90834 99472 NCCI
90834 99475 NCCI
90834 99476 NCCI
90834 99477 NCCI
90834 99478 NCCI
90834 99479 NCCI
90834 99480 NCCI
90834 99485 NCCI
90834 99486 NCCI
90834 99487 NCCI
90834 99489 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 25 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90834 99490 NCCI
90834 99495 NCCI
90834 99496 NCCI
90834 99497 NCCI
90834 99605 NCCI
90834 99606 NCCI
90834 G0176 NCCI
90834 G0177 NCCI
90834 G0270 NCCI
90834 G0271 NCCI
90834 G0380 NCCI
90834 G0381 NCCI
90834 G0382 NCCI
90834 G0383 NCCI
90834 G0384 NCCI
90834 G0396 NCCI
90834 G0397 NCCI
90834 G0406 NCCI
90834 G0407 NCCI
90834 G0408 NCCI
90834 G0409 NCCI
90834 G0410 NCCI
90834 G0411 NCCI
90834 G0425 NCCI
90834 G0442 NCCI
90834 G0443 NCCI
90834 G0444 NCCI
90834 G0445 NCCI
90834 G0446 NCCI
90834 G0447 NCCI
90834 G0459 NCCI
90834 G0463 NCCI
90834 G0473 NCCI
90836 0359T NCCI
90836 0360T NCCI
90836 0361T NCCI
90836 0362T NCCI
90836 0363T NCCI
90836 0364T NCCI
90836 0365T NCCI
90836 0366T NCCI
90836 0367T NCCI
90836 0368T NCCI
90836 0369T NCCI
90836 0370T NCCI
90836 0371T NCCI
90836 0372T NCCI
Comprehensive ComponentCode Code Source
90836 0373T NCCI
90836 0374T NCCI
90836 0405T NCCI
90836 36591 NCCI
90836 36592 NCCI
90836 36640 NCCI
90836 90832 NCCI
90836 90833 NCCI
90836 90834 NCCI
90836 90839 NCCI
90836 90840 NCCI
90836 90867 NCCI
90836 90868 NCCI
90836 90869 NCCI
90836 96116 NCCI
90836 96127 NCCI
90836 96150 NCCI
90836 96151 NCCI
90836 96152 NCCI
90836 96153 NCCI
90836 96154 NCCI
90836 96155 NCCI
90836 96160 NCCI
90836 96161 NCCI
90836 97802 NCCI
90836 97803 NCCI
90836 97804 NCCI
90836 99184 NCCI
90836 99281 NCCI
90836 99282 NCCI
90836 99283 NCCI
90836 99284 NCCI
90836 99285 NCCI
90836 99288 NCCI
90836 99291 NCCI
90836 99292 NCCI
90836 99339 NCCI
90836 99340 NCCI
90836 99354 NCCI
90836 99355 NCCI
90836 99356 NCCI
90836 99357 NCCI
90836 99358 NCCI
90836 99359 NCCI
90836 99360 NCCI
90836 99363 NCCI
90836 99364 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 26 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90836 99366 NCCI
90836 99367 NCCI
90836 99368 NCCI
90836 99374 NCCI
90836 99375 NCCI
90836 99377 NCCI
90836 99378 NCCI
90836 99379 NCCI
90836 99380 NCCI
90836 99381 NCCI
90836 99382 NCCI
90836 99383 NCCI
90836 99384 NCCI
90836 99385 NCCI
90836 99386 NCCI
90836 99387 NCCI
90836 99391 NCCI
90836 99392 NCCI
90836 99393 NCCI
90836 99394 NCCI
90836 99395 NCCI
90836 99396 NCCI
90836 99397 NCCI
90836 99401 NCCI
90836 99402 NCCI
90836 99403 NCCI
90836 99404 NCCI
90836 99406 NCCI
90836 99407 NCCI
90836 99408 NCCI
90836 99409 NCCI
90836 99411 NCCI
90836 99412 NCCI
90836 99415 NCCI
90836 99416 NCCI
90836 99429 NCCI
90836 99441 NCCI
90836 99442 NCCI
90836 99443 NCCI
90836 99444 NCCI
90836 99446 NCCI
90836 99447 NCCI
90836 99448 NCCI
90836 99449 NCCI
90836 99450 NCCI
90836 99455 NCCI
90836 99456 NCCI
Comprehensive ComponentCode Code Source
90836 99460 NCCI
90836 99461 NCCI
90836 99462 NCCI
90836 99463 NCCI
90836 99464 NCCI
90836 99465 NCCI
90836 99466 NCCI
90836 99467 NCCI
90836 99468 NCCI
90836 99469 NCCI
90836 99471 NCCI
90836 99472 NCCI
90836 99475 NCCI
90836 99476 NCCI
90836 99477 NCCI
90836 99478 NCCI
90836 99479 NCCI
90836 99480 NCCI
90836 99485 NCCI
90836 99486 NCCI
90836 99487 NCCI
90836 99489 NCCI
90836 99490 NCCI
90836 99495 NCCI
90836 99496 NCCI
90836 99605 NCCI
90836 99606 NCCI
90836 G0176 NCCI
90836 G0177 NCCI
90836 G0270 NCCI
90836 G0271 NCCI
90836 G0380 NCCI
90836 G0381 NCCI
90836 G0382 NCCI
90836 G0383 NCCI
90836 G0384 NCCI
90836 G0396 NCCI
90836 G0397 NCCI
90836 G0406 NCCI
90836 G0407 NCCI
90836 G0409 NCCI
90836 G0410 NCCI
90836 G0411 NCCI
90836 G0442 NCCI
90836 G0443 NCCI
90836 G0444 NCCI
90836 G0445 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 27 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90836 G0446 NCCI
90836 G0447 NCCI
90836 G0459 NCCI
90836 G0473 NCCI
90837 0359T NCCI
90837 0360T NCCI
90837 0361T NCCI
90837 0362T NCCI
90837 0363T NCCI
90837 0364T NCCI
90837 0365T NCCI
90837 0366T NCCI
90837 0367T NCCI
90837 0368T NCCI
90837 0369T NCCI
90837 0370T NCCI
90837 0371T NCCI
90837 0372T NCCI
90837 0373T NCCI
90837 0374T NCCI
90837 0405T NCCI
90837 36591 NCCI
90837 36592 NCCI
90837 36640 NCCI
90837 90832 NCCI
90837 90833 NCCI
90837 90834 NCCI
90837 90836 NCCI
90837 90839 NCCI
90837 90840 NCCI
90837 90845 NCCI
90837 90867 NCCI
90837 90868 NCCI
90837 90869 NCCI
90837 96116 NCCI
90837 96127 NCCI
90837 96150 NCCI
90837 96151 NCCI
90837 96152 NCCI
90837 96153 NCCI
90837 96154 NCCI
90837 96155 NCCI
90837 96160 NCCI
90837 96161 NCCI
90837 97802 NCCI
90837 97803 NCCI
90837 97804 NCCI
Comprehensive ComponentCode Code Source
90837 99184 NCCI
90837 99201 NCCI
90837 99202 NCCI
90837 99203 NCCI
90837 99204 NCCI
90837 99205 NCCI
90837 99211 NCCI
90837 99212 NCCI
90837 99213 NCCI
90837 99214 NCCI
90837 99215 NCCI
90837 99217 NCCI
90837 99218 NCCI
90837 99219 NCCI
90837 99220 NCCI
90837 99221 NCCI
90837 99222 NCCI
90837 99223 NCCI
90837 99224 NCCI
90837 99225 NCCI
90837 99226 NCCI
90837 99231 NCCI
90837 99232 NCCI
90837 99233 NCCI
90837 99234 NCCI
90837 99235 NCCI
90837 99236 NCCI
90837 99238 NCCI
90837 99239 NCCI
90837 99241 NCCI
90837 99242 NCCI
90837 99243 NCCI
90837 99244 NCCI
90837 99245 NCCI
90837 99251 NCCI
90837 99252 NCCI
90837 99253 NCCI
90837 99254 NCCI
90837 99255 NCCI
90837 99281 NCCI
90837 99282 NCCI
90837 99283 NCCI
90837 99284 NCCI
90837 99285 NCCI
90837 99288 NCCI
90837 99291 NCCI
90837 99292 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 28 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90837 99304 NCCI
90837 99305 NCCI
90837 99306 NCCI
90837 99307 NCCI
90837 99308 NCCI
90837 99309 NCCI
90837 99310 NCCI
90837 99315 NCCI
90837 99316 NCCI
90837 99318 NCCI
90837 99324 NCCI
90837 99325 NCCI
90837 99326 NCCI
90837 99327 NCCI
90837 99328 NCCI
90837 99334 NCCI
90837 99335 NCCI
90837 99336 NCCI
90837 99337 NCCI
90837 99339 NCCI
90837 99340 NCCI
90837 99341 NCCI
90837 99342 NCCI
90837 99343 NCCI
90837 99344 NCCI
90837 99345 NCCI
90837 99347 NCCI
90837 99348 NCCI
90837 99349 NCCI
90837 99350 NCCI
90837 99358 NCCI
90837 99359 NCCI
90837 99360 NCCI
90837 99363 NCCI
90837 99364 NCCI
90837 99366 NCCI
90837 99367 NCCI
90837 99368 NCCI
90837 99374 NCCI
90837 99375 NCCI
90837 99377 NCCI
90837 99378 NCCI
90837 99379 NCCI
90837 99380 NCCI
90837 99381 NCCI
90837 99382 NCCI
90837 99383 NCCI
Comprehensive ComponentCode Code Source
90837 99384 NCCI
90837 99385 NCCI
90837 99386 NCCI
90837 99387 NCCI
90837 99391 NCCI
90837 99392 NCCI
90837 99393 NCCI
90837 99394 NCCI
90837 99395 NCCI
90837 99396 NCCI
90837 99397 NCCI
90837 99401 NCCI
90837 99402 NCCI
90837 99403 NCCI
90837 99404 NCCI
90837 99406 NCCI
90837 99407 NCCI
90837 99408 NCCI
90837 99409 NCCI
90837 99411 NCCI
90837 99412 NCCI
90837 99429 NCCI
90837 99441 NCCI
90837 99442 NCCI
90837 99443 NCCI
90837 99444 NCCI
90837 99446 NCCI
90837 99447 NCCI
90837 99448 NCCI
90837 99449 NCCI
90837 99450 NCCI
90837 99455 NCCI
90837 99456 NCCI
90837 99460 NCCI
90837 99461 NCCI
90837 99462 NCCI
90837 99463 NCCI
90837 99464 NCCI
90837 99465 NCCI
90837 99466 NCCI
90837 99467 NCCI
90837 99468 NCCI
90837 99469 NCCI
90837 99471 NCCI
90837 99472 NCCI
90837 99475 NCCI
90837 99476 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 29 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90837 99477 NCCI
90837 99478 NCCI
90837 99479 NCCI
90837 99480 NCCI
90837 99485 NCCI
90837 99486 NCCI
90837 99487 NCCI
90837 99489 NCCI
90837 99490 NCCI
90837 99495 NCCI
90837 99496 NCCI
90837 99497 NCCI
90837 99605 NCCI
90837 99606 NCCI
90837 G0176 NCCI
90837 G0177 NCCI
90837 G0270 NCCI
90837 G0271 NCCI
90837 G0380 NCCI
90837 G0381 NCCI
90837 G0382 NCCI
90837 G0383 NCCI
90837 G0384 NCCI
90837 G0396 NCCI
90837 G0397 NCCI
90837 G0406 NCCI
90837 G0407 NCCI
90837 G0408 NCCI
90837 G0409 NCCI
90837 G0410 NCCI
90837 G0411 NCCI
90837 G0425 NCCI
90837 G0426 NCCI
90837 G0442 NCCI
90837 G0443 NCCI
90837 G0444 NCCI
90837 G0445 NCCI
90837 G0446 NCCI
90837 G0447 NCCI
90837 G0459 NCCI
90837 G0463 NCCI
90837 G0473 NCCI
90838 0359T NCCI
90838 0360T NCCI
90838 0361T NCCI
90838 0362T NCCI
90838 0363T NCCI
Comprehensive ComponentCode Code Source
90838 0364T NCCI
90838 0365T NCCI
90838 0366T NCCI
90838 0367T NCCI
90838 0368T NCCI
90838 0369T NCCI
90838 0370T NCCI
90838 0371T NCCI
90838 0372T NCCI
90838 0373T NCCI
90838 0374T NCCI
90838 0405T NCCI
90838 36591 NCCI
90838 36592 NCCI
90838 36640 NCCI
90838 90832 NCCI
90838 90833 NCCI
90838 90834 NCCI
90838 90836 NCCI
90838 90837 NCCI
90838 90839 NCCI
90838 90840 NCCI
90838 90845 NCCI
90838 90867 NCCI
90838 90868 NCCI
90838 90869 NCCI
90838 96116 NCCI
90838 96127 NCCI
90838 96150 NCCI
90838 96151 NCCI
90838 96152 NCCI
90838 96153 NCCI
90838 96154 NCCI
90838 96155 NCCI
90838 96160 NCCI
90838 96161 NCCI
90838 97802 NCCI
90838 97803 NCCI
90838 97804 NCCI
90838 99184 NCCI
90838 99281 NCCI
90838 99282 NCCI
90838 99283 NCCI
90838 99284 NCCI
90838 99285 NCCI
90838 99288 NCCI
90838 99291 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 30 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90838 99292 NCCI
90838 99339 NCCI
90838 99340 NCCI
90838 99354 NCCI
90838 99355 NCCI
90838 99356 NCCI
90838 99357 NCCI
90838 99358 NCCI
90838 99359 NCCI
90838 99360 NCCI
90838 99363 NCCI
90838 99364 NCCI
90838 99366 NCCI
90838 99367 NCCI
90838 99368 NCCI
90838 99374 NCCI
90838 99375 NCCI
90838 99377 NCCI
90838 99378 NCCI
90838 99379 NCCI
90838 99380 NCCI
90838 99381 NCCI
90838 99382 NCCI
90838 99383 NCCI
90838 99384 NCCI
90838 99385 NCCI
90838 99386 NCCI
90838 99387 NCCI
90838 99391 NCCI
90838 99392 NCCI
90838 99393 NCCI
90838 99394 NCCI
90838 99395 NCCI
90838 99396 NCCI
90838 99397 NCCI
90838 99401 NCCI
90838 99402 NCCI
90838 99403 NCCI
90838 99404 NCCI
90838 99406 NCCI
90838 99407 NCCI
90838 99408 NCCI
90838 99409 NCCI
90838 99411 NCCI
90838 99412 NCCI
90838 99415 NCCI
90838 99416 NCCI
Comprehensive ComponentCode Code Source
90838 99429 NCCI
90838 99441 NCCI
90838 99442 NCCI
90838 99443 NCCI
90838 99444 NCCI
90838 99446 NCCI
90838 99447 NCCI
90838 99448 NCCI
90838 99449 NCCI
90838 99450 NCCI
90838 99455 NCCI
90838 99456 NCCI
90838 99460 NCCI
90838 99461 NCCI
90838 99462 NCCI
90838 99463 NCCI
90838 99464 NCCI
90838 99465 NCCI
90838 99466 NCCI
90838 99467 NCCI
90838 99468 NCCI
90838 99469 NCCI
90838 99471 NCCI
90838 99472 NCCI
90838 99475 NCCI
90838 99476 NCCI
90838 99477 NCCI
90838 99478 NCCI
90838 99479 NCCI
90838 99480 NCCI
90838 99485 NCCI
90838 99486 NCCI
90838 99487 NCCI
90838 99489 NCCI
90838 99490 NCCI
90838 99495 NCCI
90838 99496 NCCI
90838 99605 NCCI
90838 99606 NCCI
90838 G0176 NCCI
90838 G0177 NCCI
90838 G0270 NCCI
90838 G0271 NCCI
90838 G0380 NCCI
90838 G0381 NCCI
90838 G0382 NCCI
90838 G0383 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 31 of 837
-
Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90838 G0384 NCCI
90838 G0396 NCCI
90838 G0397 NCCI
90838 G0406 NCCI
90838 G0407 NCCI
90838 G0408 NCCI
90838 G0409 NCCI
90838 G0410 NCCI
90838 G0411 NCCI
90838 G0425 NCCI
90838 G0426 NCCI
90838 G0442 NCCI
90838 G0443 NCCI
90838 G0444 NCCI
90838 G0445 NCCI
90838 G0446 NCCI
90838 G0447 NCCI
90838 G0459 NCCI
90838 G0473 NCCI
90839 0359T NCCI
90839 0360T NCCI
90839 0361T NCCI
90839 0362T NCCI
90839 0363T NCCI
90839 0364T NCCI
90839 0365T NCCI
90839 0366T NCCI
90839 0367T NCCI
90839 0368T NCCI
90839 0369T NCCI
90839 0370T NCCI
90839 0371T NCCI
90839 0372T NCCI
90839 0373T NCCI
90839 0374T NCCI
90839 36591 NCCI
90839 36592 NCCI
90839 36640 NCCI
90839 90785 NCCI
90839 90845 NCCI
90839 90846 NCCI
90839 90847 NCCI
90839 90849 NCCI
90839 90853 NCCI
90839 90863 NCCI
90839 90865 NCCI
90839 90867 NCCI
Comprehensive ComponentCode Code Source
90839 90868 NCCI
90839 90869 NCCI
90839 90870 NCCI
90839 90875 NCCI
90839 90876 NCCI
90839 90880 NCCI
90839 90882 NCCI
90839 90885 NCCI
90839 90887 NCCI
90839 90889 NCCI
90839 96116 NCCI
90839 96127 NCCI
90839 96150 NCCI
90839 96151 NCCI
90839 96152 NCCI
90839 96153 NCCI
90839 96154 NCCI
90839 96155 NCCI
90839 97802 NCCI
90839 97803 NCCI
90839 97804 NCCI
90839 99605 NCCI
90839 99606 NCCI
90839 G0176 NCCI
90839 G0177 NCCI
90839 G0270 NCCI
90839 G0271 NCCI
90839 G0396 NCCI
90839 G0397 NCCI
90839 G0409 NCCI
90839 G0410 NCCI
90839 G0411 NCCI
90839 G0442 NCCI
90839 G0443 NCCI
90839 G0444 NCCI
90839 G0445 NCCI
90839 G0446 NCCI
90839 G0447 NCCI
90839 G0459 NCCI
90839 G0473 NCCI
90840 0359T NCCI
90840 0360T NCCI
90840 0361T NCCI
90840 0362T NCCI
90840 0363T NCCI
90840 0364T NCCI
90840 0365T NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 2/16/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 32 of 837
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Effective Date of Service: 4/1/2017
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
90840 0366T NCCI
90840 0367T NCCI
90840 0368T NCCI
90840 0369T NCCI
90840 0370T NCCI
90840 0371T NCCI
90840 0372T NCCI
90840 0373T NCCI
90840 0374T NCCI
90840 36591 NCCI
90840 36592 NCCI
90840 36640 NCCI
90840 90785 NCCI
90840 90845 NCCI
90840 90846 NCCI
90840 90847 NCCI
90840 90849 NCCI
90840 90853 NCCI
90840 90863 NCCI
90840 90865 NCCI
90840 90867 NCCI
90840 90868 NCCI
90840 90869 NCCI
90840 90870 NCCI
90840 90875 NCCI
90840 90876 NCCI
90840 90880 NCCI
90840 90882 NCCI
90840 90885 NCCI
90840 90887 NCCI
90840 90889 NCCI
90840 96116 NCC