Bundled, Inactive, and Non-Payable Codes for 2014: Medicare Physician Fee Schedule Database

2014The Centers for Medicare & Medicaid Services (CMS) designates the status of HCPCS and CPT codes in the Medicare Physician Fee Schedule Database (MPFSDB). The status of codes may be updated periodically throughout the year and when the calendar year changes. Codes designated as Status A are active codes, are separately payable under the Medicare Physician Fee Schedule (assuming any existing coverage criteria are met), and have associated Relative Value Units (RVUs) and payment amounts. The list of Status A codes is extensive, and these codes are not listed in this article.

February 17, 2014© 2014 Copyright, CGS Administrators, LLC.

Status B 2

Status C 3

Status E 9

Status I 15

Status M 24

Status N 30

Status P 35

Status Q 37

Status R 38

Status T 40

Status X 41

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 2Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

STATUS BStatus B codes are bundled. Payment for these services is always included in payment for other services not specified. There are no RVUs or payment amounts for these codes, and separate payment is not made.

CPT Codes Modifier1585020930209362284136000364163820490885908879088992352923539235492355923589237192531925329253392534926059260692618929219292592929929349293892944937409377094005941509604096902

CPT Codes Modifier9701097602989609896198962990009900199002990249905099051990539905699058990609907099071990789908099090990919910099116991359914099288993399934099358993599936399364993669936799368

CPT Codes Modifier9937499377993799938099446994479944899449994859948699487994889948994150 2694150 TC

HCPCS Codes ModifierA4262A4263A4270A4300A4550G0269Q3031R0076

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 3Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

STATUS CStatus C codes are priced by each contractor. CGS establishes RVUs and payment amounts for these services, generally on an individual basis, based on review of documentation (such as operative reports).

CPT Codes Modifier15847159991799919499209992108821089212992149921742217432189922899229992392924940249992599926989272992759927899288992979929999309993129931599318993285532856329993393333944

CPT Codes Modifier33999348413484234843348443484534846348473484836299371953750137799381293858938999394993959940799408994159941899422994269942999432894349643499436474364843659437754388143882

CPT Codes Modifier43999441374423844715447994489944979454994599946999471434714447145473794739947579479994855148999493294965949906499995032350325505495094951999538995444054699555595589958578

CPT Codes Modifier58579586795897458999598975989859899606596069963043630446499965757669996729967399675996799968399688996939969799699496997970170705557055770558705597229172292735307419074235

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 4

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier743007430174305743287432974330743407435574360743637442074425744457445074470747427477575801758037580575807758107589475896758987594575946759527595375954759567595775958759597597075980759827600176125

CPT Codes Modifier764967649776498764997693276940769417694576975769987699977013770227729977371773997749977520775227752377525777997809978199782827829978399784147845978491784927849978599786087869978799788117881278813

CPT Codes Modifier788147881578816789997930079445799998648588199882998839989240908679086890869908999095290953909999129992499927009297892979929929299393299933159331793318935309353193532935339356193562935719357293600

CPT Codes Modifier936029360393609936109361293615936169361893619936209362193622936239362493631936409364193662937459379993998946429477294774947759477694777947999519995824959439595195965959669596795999960209637996549

STATUS C

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 5

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier969999703997139976109779999082991439914499145991489914999150991999948199482994990019T0042T0051T0052T0053T0054T0055T0058T0059T0071T0072T0075T0075T 260075T TC0076T0076T 260076T TC0092T0095T0098T0099T0100T0101T

CPT Codes Modifier0102T0103T0106T0107T0108T0109T0110T0111T0123T0126T0159T0159T 260159T TC0163T0164T0165T0169T0171T0172T0174T0175T0178T0179T0180T0181T0182T0182T 260182T TC0184T0190T0191T0195T0196T0197T0198T0199T0200T0201T0202T

CPT Codes Modifier0205T0206T0207T0208T0209T0210T0211T0212T0213T0214T0215T0216T0217T0218T0219T0220T0221T0222T0223T0224T0225T0226T0227T0228T0229T0230T0231T0232T0233T0234T0235T0236T0237T0238T0239T0240T0240T 260240T TC0241T

CPT Codes Modifier0241T 260241T TC0243T0243T 260243T TC0244T0244T 260244T TC0245T0246T0247T0248T0249T0253T0254T0255T0255T 260255T TC0262T0263T0264T0265T0266T0267T0268T0269T0270T0271T0272T0273T0274T0275T0278T0281T0282T0283T0284T0285T0286T

STATUS C

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 6

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier0287T0288T0289T0290T0291T0292T0293T0294T0295T0296T0297T0298T0299T0300T0301T0302T0303T0304T0305T0306T0307T0308T0309T0310T0311T0312T0313T0314T0315T0316T0317T0319T0320T0321T0322T0323T0324T0325T0326T

CPT Codes Modifier0327T0328T0329T0330T0331T0332T0333T0334T0335T0336T0337T0338T0339T0340T0341T0342T0343T0344T0345T0346T70170 TC70555 TC70557 TC70558 TC70559 TC72291 TC72292 TC73530 TC74190 TC74235 TC74300 TC74301 TC74305 TC74328 TC74329 TC74330 TC74340 TC74355 TC74360 TC

CPT Codes Modifier74363 TC74420 TC74425 TC74445 TC74450 TC74470 TC74742 TC74775 TC75801 TC75803 TC75805 TC75807 TC75810 TC75894 TC75896 TC75898 TC75945 TC75946 TC75952 TC75953 TC75954 TC75956 TC75957 TC75958 TC75959 TC75970 TC75980 TC75982 TC76001 TC76125 TC76496 2676496 TC76497 2676497 TC76498 2676498 TC76499 2676499 TC76932 TC

CPT Codes Modifier76940 TC76941 TC76945 TC76975 TC76998 TC76999 2676999 TC77013 TC77022 TC77299 2677299 TC77399 2677399 TC77499 2677499 TC77799 2677799 TC78099 2678099 TC78199 2678199 TC78282 TC78299 2678299 TC78399 2678399 TC78414 TC78459 TC78491 TC78492 TC78499 2678499 TC78599 2678599 TC78608 TC78699 2678699 TC78799 2678799 TC

STATUS C

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 7

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier78811 TC78812 TC78813 TC78814 TC78815 TC78816 TC78999 2678999 TC79300 TC79445 TC79999 2679999 TC88199 2688199 TC88399 2688399 TC91299 2691299 TC92499 2692499 TC92978 TC92979 TC93315 TC93317 TC93318 TC93530 TC93531 TC93532 TC93533 TC93561 TC93562 TC93571 TC93572 TC93600 TC93602 TC93603 TC93609 TC93610 TC93612 TC

CPT Codes Modifier93615 TC93616 TC93618 TC93619 TC93620 TC93621 TC93622 TC93623 TC93624 TC93631 TC93640 TC93641 TC93662 TC93745 2693745 TC93799 2693799 TC94772 2694772 TC94799 2694799 TC95824 TC95943 2695943 TC95951 TC95965 TC95966 TC95967 TC96020 TC

HCPCS Codes ModifierA4641A4642A9500A9501A9502A9503A9504A9505A9507A9508A9509A9510A9512A9516A9517A9521A9524A9526A9527A9528A9529A9530A9531A9532A9536A9537A9538A9539A9540A9541A9542A9543A9544A9545A9546A9547A9548A9550A9551

HCPCS Codes ModifierA9552A9553A9554A9555A9556A9557A9558A9559A9560A9561A9562A9563A9564A9566A9567A9568A9569A9570A9571A9572A9580A9599A9600A9699G0186G0339G0340G0398G0398 26G0398 TCG0399G0399 26G0399 TCG0400G0400 26G0400 TCG0456G0457G0460

STATUS C

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 8

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierQ3001R0070R0075

STATUS C

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 9Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

STATUS EStatus E codes are excluded from the MPFS by regulation. There are no RVUs or payment amounts for these codes, and separate payment is not made.

CPT Codes Modifier90296903719037590376903859039390396904769047790581905859058690632906339063490636906459064690647906489064990650906759067690680906819069090691906929069390696906989070090702

CPT Codes Modifier9070390704907059070690707907089071090712907139071490715907169071790719907209072190725907279073390734907359073690749

HCPCS Codes ModifierA9150A9700G0157G0158G0159G0160G0161G0162G0163G0164G0251G0257G0259G0260G0293G0294G0448G0458J0120J0129J0130J0131J0132J0133J0135J0150J0151J0171J0178J0180J0190J0200J0205J0207

HCPCS Codes ModifierJ0210J0215J0220J0221J0256J0257J0270J0275J0278J0280J0282J0285J0287J0288J0289J0290J0295J0300J0330J0348J0350J0360J0364J0365J0380J0390J0395J0400J0401J0456J0461J0470J0475J0476

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 10

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierJ0480J0485J0490J0500J0515J0520J0558J0561J0583J0585J0586J0587J0588J0592J0594J0595J0597J0598J0600J0610J0620J0630J0636J0637J0638J0640J0641J0670J0690J0692J0694J0696J0697J0698J0702J0706J0710J0712J0713

STATUS E

HCPCS Codes ModifierJ0715J0716J0717J0720J0725J0735J0740J0743J0744J0745J0760J0770J0775J0780J0795J0800J0833J0834J0840J0850J0878J0881J0882J0885J0886J0890J0894J0895J0897J0900J0945J1000J1020J1030J1040J1050J1060J1070J1080

HCPCS Codes ModifierJ1094J1100J1110J1120J1160J1162J1165J1170J1180J1190J1200J1205J1212J1230J1240J1245J1250J1260J1265J1267J1270J1290J1300J1320J1324J1325J1327J1330J1335J1364J1380J1410J1430J1435J1436J1438J1442J1446J1450

HCPCS Codes ModifierJ1451J1452J1453J1455J1457J1458J1459J1460J1556J1557J1559J1560J1561J1562J1566J1568J1569J1570J1571J1572J1573J1580J1590J1595J1599J1600J1602J1610J1620J1626J1630J1631J1640J1642J1644J1645J1650J1652J1655

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 11

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierJ1670J1675J1700J1710J1720J1725J1730J1740J1741J1742J1743J1744J1745J1750J1756J1786J1790J1800J1810J1815J1817J1830J1835J1840J1850J1885J1890J1930J1931J1940J1945J1950J1953J1955J1956J1960J1980J1990J2001

HCPCS Codes ModifierJ2010J2020J2060J2150J2170J2175J2180J2185J2210J2212J2248J2250J2260J2265J2270J2271J2275J2278J2280J2300J2310J2315J2320J2323J2325J2353J2354J2355J2357J2358J2360J2370J2400J2405J2410J2425J2426J2430J2440

HCPCS Codes ModifierJ2460J2469J2501J2503J2504J2505J2507J2510J2513J2515J2540J2543J2545J2550J2560J2562J2590J2597J2650J2670J2675J2680J2690J2700J2710J2720J2724J2725J2730J2760J2765J2770J2778J2780J2783J2785J2788J2790J2791

HCPCS Codes ModifierJ2792J2793J2794J2795J2796J2800J2805J2810J2820J2850J2910J2916J2920J2930J2940J2941J2950J2993J2995J2997J3000J3010J3030J3060J3070J3095J3101J3105J3110J3120J3130J3140J3150J3230J3240J3243J3246J3250J3260

STATUS E

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 12

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierJ3262J3265J3280J3285J3300J3301J3302J3303J3305J3310J3315J3320J3350J3355J3357J3360J3364J3365J3370J3385J3396J3400J3410J3411J3415J3420J3430J3465J3470J3471J3472J3473J3475J3480J3485J3486J3489J3490J3530

HCPCS Codes ModifierJ3590J7030J7040J7042J7050J7060J7070J7100J7110J7120J7131J7178J7180J7183J7185J7186J7187J7189J7196J7308J7309J7310J7311J7312J7315J7316J7321J7323J7324J7325J7326J7330J7335J7502J7507J7508J7511J7513J7515

HCPCS Codes ModifierJ7516J7517J7518J7520J7525J7527J7604J7605J7606J7607J7608J7609J7610J7611J7612J7613J7614J7615J7620J7622J7624J7626J7627J7628J7629J7631J7632J7633J7634J7635J7636J7637J7638J7639J7640J7641J7642J7643J7644

HCPCS Codes ModifierJ7645J7647J7648J7649J7650J7657J7658J7659J7660J7665J7667J7668J7669J7670J7674J7676J7680J7681J7682J7683J7684J7685J7686J7699J7799J8498J8501J8510J8520J8521J8530J8540J8560J8562J8597J8600J8610J8650J8700

STATUS E

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 13

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierJ8705J8999J9000J9010J9015J9017J9019J9020J9025J9027J9031J9033J9035J9040J9041J9042J9043J9045J9047J9050J9055J9060J9065J9070J9098J9100J9120J9130J9150J9151J9155J9160J9165J9171J9175J9178J9179J9181J9185

HCPCS Codes ModifierJ9190J9200J9201J9202J9206J9207J9208J9209J9211J9212J9213J9214J9215J9216J9217J9218J9219J9225J9226J9228J9230J9245J9250J9260J9261J9262J9263J9264J9265J9266J9268J9270J9280J9293J9300J9302J9303J9305J9306

HCPCS Codes ModifierJ9307J9310J9315J9320J9328J9330J9340J9351J9354J9355J9357J9360J9370J9371J9390J9395J9400J9600J9999P9010P9011P9012P9016P9017P9019P9020P9021P9022Q0081Q0083Q0084Q0085Q0138Q0139Q0161Q0162Q0478Q0479Q0480

HCPCS Codes ModifierQ0481Q0482Q0483Q0484Q0485Q0486Q0487Q0488Q0489Q0490Q0491Q0492Q0493Q0494Q0495Q0496Q0497Q0498Q0499Q0500Q0501Q0502Q0503Q0504Q0506Q0507Q0508Q0509Q0510Q0511Q0512Q0513Q0514Q0515Q2004Q2009Q2017Q2026Q2028

STATUS E

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 14

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierQ2043Q2049Q2050Q2052Q3027Q4074Q4081Q4082Q4100Q4101Q4102Q4103Q4104Q4105Q4106Q4107Q4108Q4110Q4111Q4112Q4113Q4114Q4115Q4116Q4117Q4118Q4119Q4120Q4121Q4122Q4123Q4124Q4125Q4126Q4127Q4128Q4129Q4130Q4137

HCPCS Codes ModifierQ4138Q4139Q4140Q4141Q4142Q4143Q4145Q4146Q4147Q4148Q4149Q5001Q5002Q5003Q5004Q5005Q5006Q5007Q5008Q5009Q5010Q9951Q9953Q9954Q9955Q9956Q9957Q9958Q9959Q9960Q9961Q9962Q9963Q9964Q9965Q9966Q9967Q9968Q9969

STATUS E

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 15Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

STATUS I Status I codes are not valid for Medicare purposes. Medicare uses another CPT or HCPCS code for reporting these services.

CPT Codes Modifier272152721627217272183820738208382093821038211382123821338214382154470576140800558010080101801048150081503815068150881509815108151181512815998834288342 2688342 TC8834388343 2688343 TC

CPT Codes Modifier88375902819028390287902889029190384903869038990399906589072390738907489086392630926339512095125951309513195132951339513495941970059700697014992419924299243992449924599251

CPT Codes Modifier9925299253992549925599375993789950099501995029950399504995059950699507995099951099511995129960099601996020001F0005F0012F0014F0015F0501F0502F0503F0505F0507F0514F0516F0519F

CPT Codes Modifier0525F0535F0545F0550F0551F0555F0575F0580F0581F0582F0583F0584F1000F1002F1003F1004F1005F1008F1015F1018F1019F1022F1026F1030F1034F1035F1050F1052F1055F1060F1061F1065F1066F1070F

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 16

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier1071F1110F1116F1118F1121F1127F1128F1134F1135F1136F1137F1150F1151F1152F1153F1157F1158F1159F1160F1180F1182F1183F1450F1451F1500F1501F1502F1503F1504F1505F2001F2002F2004F2014F2018F2020F2028F2029F2030F

CPT Codes Modifier2031F2035F2044F2050F2060F3006F3008F3011F3015F3018F3019F3020F3025F3027F3028F3035F3037F3040F3042F3055F3056F3073F3074F3075F3077F3078F3079F3080F3082F3083F3084F3085F3088F3089F3090F3091F3092F3093F3110F

CPT Codes Modifier3111F3112F3115F3117F3118F3119F3130F3132F3140F3141F3142F3150F3200F3216F3218F3220F3230F3266F3268F3278F3279F3280F3281F3290F3291F3292F3293F3294F3317F3318F3324F3325F3330F3331F3351F3352F3353F3354F3450F

CPT Codes Modifier3451F3452F3490F3491F3492F3493F3497F3498F3500F3502F3503F3511F3512F3513F3514F3515F3520F3550F3551F3552F3555F3572F3573F3650F3751F3752F3753F3754F3755F3756F3757F3758F3759F3760F3761F3762F3763F4003F4011F

STATUS I

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 17

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier4012F4014F4015F4016F4017F4018F4019F4030F4033F4041F4050F4051F4052F4053F4054F4055F4056F4058F4060F4062F4063F4064F4065F4066F4067F4069F4070F4073F4077F4079F4133F4134F4135F4136F4145F4149F4150F4153F4155F

CPT Codes Modifier4157F4158F4159F4163F4165F4167F4168F4169F4174F4176F4178F4180F4181F4182F4185F4186F4188F4189F4190F4191F4200F4201F4210F4220F4221F4230F4240F4242F4267F4268F4269F4270F4271F4274F4276F4279F4280F4290F4293F

CPT Codes Modifier4300F4301F4305F4306F4324F4326F4330F4350F4450F4470F4480F4481F4540F4541F4550F4551F4552F4553F4554F4555F4556F4557F4558F4559F4560F4561F4562F4563F5005F5020F5060F5062F5100F5200F5250F6005F6040F6070F6080F

STATUS I

CPT Codes Modifier6090F6100F7020F9001F9002F9005F

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 18

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierA0021A0080A0090A0100A0110A0120A0130A0140A0160A0170A0180A0190A0200A0210A0225A0380A0390A0998A4232A4264A4266A4267A4268A4269A4466A4555A4566A4570A4580A4590A9152A9153A9180A9272A9274A9279D0210D0220D0230

HCPCS Codes ModifierD0290D0310D0320D0321D0322D0330D0340D0350D1352D3354D4210D4211D4212D5913D5914D5915D5916D5919D5922D5923D5924D5925D5926D5927D5928D5929D5931D5932D5933D5934D5935D5936D5937D5952D5953D5954D5955D5958D5959

HCPCS Codes ModifierD5960D5982D5988D5992D5993D5994D5999D6010D6011D6040D6050D6055D6080D6090D6095D6100D6101D6102D6103D6104D6199D7251D7285D7286D7287D7295D7310D7320D7340D7350D7410D7411D7412D7413D7414D7415D7440D7441D7450

HCPCS Codes ModifierD7451D7460D7461D7465D7471D7472D7473D7485D7490D7510D7520D7530D7540D7550D7560D7610D7620D7630D7640D7650D7660D7670D7671D7680D7710D7720D7730D7740D7750D7760D7770D7771D7780D7810D7820D7830D7840D7850D7852

STATUS I

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 19

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierD7854D7856D7858D7860D7865D7870D7872D7873D7874D7875D7876D7877D7880D7899D7910D7911D7912D7920D7921D7941D7943D7944D7945D7946D7947D7948D7949D7950D7955D7960D7970D7971D7972D7980D7981D7982D7983D7990D7991

HCPCS Codes ModifierD7995D7996D7999D9210D9211D9212D9215D9220D9221D9241D9242D9310D9410D9420D9430D9440D9450D9610D9985D9999G8559G8560G8561G8562G8563G8564G8565G8566G8567G8568G9050G9051G9052G9053G9054G9055G9056G9057G9058

HCPCS Codes ModifierG9059G9060G9061G9062H0001H0002H0003H0004H0005H0006H0007H0008H0009H0010H0011H0012H0013H0014H0015H0016H0017H0018H0019H0020H0021H0022H0023H0024H0025H0026H0027H0028H0029H0030H0031H0032H0033H0034H0035

HCPCS Codes ModifierH0036H0037H0038H0039H0040H0041H0042H0043H0044H0045H0046H0047H0048H0049H0050H1000H1001H1002H1003H1004H1005H1010H1011H2000H2001H2010H2011H2012H2013H2014H2015H2016H2017H2018H2019H2020H2021H2022H2023

STATUS I

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 20

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierH2024H2025H2026H2027H2028H2029H2030H2031H2032H2033H2034H2035H2036H2037J1826J7306J7307J8565P7001Q3028S0012S0014S0017S0020S0021S0023S0028S0030S0032S0034S0039S0040S0073S0074S0077S0078S0080S0081S0088

HCPCS Codes ModifierS0090S0091S0092S0093S0104S0106S0108S0109S0117S0119S0122S0126S0128S0132S0136S0137S0138S0139S0140S0142S0145S0148S0155S0156S0157S0160S0164S0166S0169S0170S0171S0172S0174S0175S0176S0177S0178S0179S0182

HCPCS Codes ModifierS0183S0187S0189S0190S0191S0194S0195S0197S0199S0201S0207S0208S0209S0215S0220S0221S0250S0255S0257S0260S0265S0270S0271S0272S0273S0274S0280S0281S0302S0310S0315S0316S0317S0320S0340S0341S0342S0353S0354

HCPCS Codes ModifierS0390S0395S0400S0500S0504S0506S0508S0510S0512S0514S0515S0516S0518S0580S0581S0590S0592S0595S0596S0601S0610S0612S0613S0618S0620S0621S0622S0630S0800S0810S0812S1001S1002S1015S1016S1030S1031S1040S1090

STATUS I

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 21

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierS2053S2054S2055S2060S2061S2065S2066S2067S2068S2070S2079S2080S2083S2095S2102S2103S2107S2112S2115S2117S2118S2120S2140S2142S2150S2152S2202S2205S2206S2207S2208S2209S2225S2230S2235S2260S2265S2266S2267

HCPCS Codes ModifierS2300S2325S2340S2341S2342S2348S2350S2351S2360S2361S2400S2401S2402S2403S2404S2405S2409S2411S2900S3000S3005S3600S3601S3620S3630S3645S3650S3652S3655S3708S3721S3722S3800S3840S3841S3842S3844S3845S3846

HCPCS Codes ModifierS3849S3850S3852S3853S3854S3855S3861S3865S3866S3870S3890S3900S3902S3904S4005S4011S4013S4014S4015S4016S4017S4018S4020S4021S4022S4023S4025S4026S4027S4028S4030S4031S4035S4037S4040S4042S4981S4989S4990

HCPCS Codes ModifierS4991S4993S4995S5000S5001S5010S5011S5012S5013S5014S5035S5036S5100S5101S5102S5105S5108S5109S5110S5111S5115S5116S5120S5121S5125S5126S5130S5131S5135S5136S5140S5141S5145S5146S5150S5151S5160S5161S5162

STATUS I

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 22

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierS5165S5170S5175S5180S5181S5185S5190S5199S5497S5498S5501S5502S5517S5518S5520S5521S5522S5523S5550S5551S5552S5553S5560S5561S5565S5566S5570S5571S8030S8035S8037S8040S8042S8055S8080S8085S8092S8096S8097

HCPCS Codes ModifierS8100S8101S8110S8120S8121S8130S8131S8185S8186S8189S8210S8262S8265S8270S8301S8415S8420S8421S8422S8423S8424S8425S8426S8427S8428S8429S8430S8431S8450S8451S8452S8460S8490S8930S8940S8948S8950S8990S8999

HCPCS Codes ModifierS9001S9007S9015S9024S9025S9034S9055S9056S9061S9083S9088S9090S9097S9098S9110S9117S9122S9123S9124S9125S9126S9127S9128S9129S9131S9140S9141S9145S9150S9152S9208S9209S9211S9212S9213S9214S9325S9326S9327

HCPCS Codes ModifierS9328S9329S9330S9331S9335S9336S9338S9339S9340S9341S9342S9343S9345S9346S9347S9348S9349S9351S9353S9355S9357S9359S9361S9363S9364S9365S9366S9367S9368S9370S9372S9373S9374S9375S9376S9377S9379S9381S9401

STATUS I

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 23

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierS9430S9433S9434S9435S9436S9437S9438S9439S9441S9442S9443S9444S9445S9446S9447S9449S9451S9452S9453S9454S9455S9460S9465S9470S9472S9473S9474S9475S9476S9480S9482S9484S9485S9490S9494S9497S9500S9501S9502

HCPCS Codes ModifierS9503S9504S9529S9537S9538S9542S9558S9559S9560S9562S9590S9810S9900S9960S9961S9970S9975S9976S9977S9981S9982S9986S9988S9989S9990S9991S9992S9994S9996S9999T1000T1001T1002T1003T1004T1005T1006T1007T1009

HCPCS Codes ModifierT1010T1012T1013T1014T1015T1016T1017T1018T1019T1020T1021T1022T1023T1024T1025T1026T1027T1028T1029T1030T1031T1502T1503T1505T1999T2001T2002T2003T2004T2005T2007T2010T2011T2012T2013T2014T2015T2016T2017

HCPCS Codes ModifierT2018T2019T2020T2021T2022T2023T2024T2025T2026T2027T2028T2029T2030T2031T2032T2033T2034T2035T2036T2037T2038T2039T2040T2041T2042T2043T2044T2045T2046T2048T2049T2101T4541T4542T5001T5999

STATUS I

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 24Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

CPT Codes Modifier0500F0509F0513F0517F0518F0520F0521F0526F0528F0529F0540F0556F0557F1006F1007F1010F1011F1012F1031F1032F1033F1036F1038F1039F1040F1090F1091F1100F1101F1111F1119F1123F1124F1125F

CPT Codes Modifier1126F1130F1170F1175F1181F1200F1205F1220F1400F1460F1461F1490F1491F1493F1494F2000F2010F2015F2016F2019F2021F2022F2024F2026F2027F2040F3014F3016F3017F3021F3022F3023F3038F3044F

CPT Codes Modifier3045F3046F3048F3049F3050F3060F3061F3062F3066F3072F3095F3096F3100F3120F3125F3155F3160F3170F3210F3215F3250F3260F3265F3267F3269F3270F3271F3272F3273F3274F3284F3285F3288F3300F

CPT Codes Modifier3301F3315F3316F3319F3320F3321F3322F3323F3328F3340F3341F3342F3343F3344F3345F3350F3370F3372F3374F3376F3378F3380F3382F3384F3386F3388F3390F3394F3395F3455F3470F3471F3472F3475F

STATUS MStatus M codes are measurement codes and are used for reporting purposes only. There are no RVUs or payment amounts for these codes, which include Quality Data Codes (QDCs) associated with the Physician Quality Reporting System.

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 25

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier3476F3494F3495F3496F3510F3517F3570F3700F3720F3725F3750F4000F4001F4004F4005F4008F4010F4013F4025F4035F4037F4040F4042F4043F4044F4045F4046F4047F4048F4049F4075F4084F4086F4090F4095F4100F4110F4115F4120F

CPT Codes Modifier4124F4130F4131F4132F4140F4142F4144F4148F4151F4164F4171F4172F4175F4177F4179F4187F4192F4193F4194F4195F4196F4245F4248F4250F4255F4256F4260F4261F4265F4266F4320F4322F4325F4328F4340F4400F4500F4510F4525F

CPT Codes Modifier4526F5010F5015F5050F6010F6015F6020F6030F6045F6101F6102F6110F6150F7010F7025F9003F9004F9006F9007F

STATUS M

HCPCS Codes ModifierG0908G0909G0910G0913G0914G0915G0916G0917G0918G0919G0920G0921G0922G8126G8127G8128G8395G8396G8397G8398G8399G8400G8401G8404G8405G8406G8410G8415G8416G8417G8418G8419G8420G8421G8422G8427G8428G8430G8431

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 26

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierG8432G8433G8442G8450G8451G8452G8458G8460G8461G8464G8465G8473G8474G8475G8476G8477G8478G8482G8483G8484G8485G8486G8487G8489G8490G8491G8492G8493G8494G8495G8496G8497G8498G8499G8500G8501G8502G8506G8509

HCPCS Codes ModifierG8510G8511G8530G8531G8532G8535G8536G8539G8540G8541G8542G8543G8544G8545G8547G8548G8549G8551G8552G8569G8570G8571G8572G8573G8574G8575G8576G8577G8578G8579G8580G8581G8582G8583G8584G8585G8586G8587G8593

HCPCS Codes ModifierG8594G8595G8597G8598G8599G8600G8601G8602G8627G8628G8629G8630G8631G8632G8633G8634G8635G8645G8646G8647G8648G8649G8650G8651G8652G8653G8654G8655G8656G8657G8658G8659G8660G8661G8662G8663G8664G8665G8666

HCPCS Codes ModifierG8667G8668G8669G8670G8671G8672G8673G8674G8682G8683G8685G8694G8696G8697G8698G8699G8700G8701G8702G8703G8704G8705G8706G8707G8708G8709G8710G8711G8712G8713G8714G8717G8718G8720G8721G8722G8723G8724G8725

STATUS M

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 27

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierG8726G8728G8730G8731G8732G8733G8734G8735G8736G8737G8738G8739G8740G8749G8751G8752G8753G8754G8755G8756G8757G8758G8759G8761G8762G8763G8764G8765G8767G8768G8769G8770G8771G8772G8773G8774G8775G8776G8777

HCPCS Codes ModifierG8778G8779G8780G8781G8782G8783G8784G8785G8797G8798G8806G8807G8808G8809G8810G8811G8815G8816G8817G8818G8825G8826G8833G8834G8838G8839G8840G8841G8842G8843G8844G8845G8846G8848G8849G8850G8851G8852G8853

HCPCS Codes ModifierG8854G8855G8856G8857G8858G8859G8860G8861G8862G8863G8864G8865G8866G8867G8868G8869G8870G8871G8872G8873G8874G8875G8876G8877G8878G8879G8880G8881G8882G8883G8884G8885G8886G8887G8888G8889G8890G8891G8892

HCPCS Codes ModifierG8893G8894G8895G8896G8897G8898G8899G8900G8902G8903G8904G8905G8906G8923G8924G8925G8926G8927G8928G8929G8930G8931G8932G8933G8934G8935G8936G8937G8938G8939G8940G8941G8942G8943G8944G8946G8947G8948G8949

STATUS M

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 28

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierG8950G8951G8952G8953G8955G8956G8957G8958G8959G8960G8961G8962G8963G8964G8965G8966G8967G8968G8969G8970G8971G8972G8973G8974G8975G8976G8977G9063G9064G9065G9066G9067G9068G9069G9070G9071G9072G9073G9074

HCPCS Codes ModifierG9075G9077G9078G9079G9080G9083G9084G9085G9086G9087G9088G9089G9090G9091G9092G9093G9094G9095G9096G9097G9098G9099G9100G9101G9102G9103G9104G9105G9106G9107G9108G9109G9110G9111G9112G9113G9114G9115G9116

HCPCS Codes ModifierG9117G9123G9124G9125G9126G9128G9129G9130G9131G9132G9133G9134G9135G9136G9137G9138G9139G9188G9189G9190G9191G9192G9193G9194G9195G9196G9197G9198G9199G9200G9201G9202G9203G9204G9205G9206G9207G9208G9209

HCPCS Codes ModifierG9210G9211G9212G9213G9214G9215G9216G9217G9218G9219G9220G9221G9222G9223G9224G9225G9226G9227G9228G9229G9230G9231G9232G9233G9234G9235G9236G9237G9238G9239G9240G9241G9242G9243G9244G9245G9246G9247G9248

STATUS M

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 29

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierG9249G9250G9251G9252G9253G9254G9255G9256G9257G9258G9259G9260G9261G9262G9263G9264G9265G9266G9267G9268G9269G9270G9271G9272G9273G9274G9275G9276G9277G9278G9279G9280G9281G9282G9283G9284G9285G9286G9287

HCPCS Codes ModifierG9288G9289G9290G9291G9292G9293G9294G9295G9296G9297G9298G9299G9300G9301G9302G9303G9304G9305G9306G9307G9308G9309G9310G9311G9312G9313G9314G9315G9316G9317G9318G9319G9320G9321G9322G9323G9324G9325G9326

HCPCS Codes ModifierG9327G9328G9329G9340G9341G9342G9343G9344G9345G9346G9347G9348G9349G9350G9351G9352G9353G9354G9355G9356G9357G9358G9359G9360

STATUS M

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 30Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

STATUS N Status N codes are always non-covered. There are no RVUs or payment amounts for these codes, and separate payment is not made.

CPT Codes Modifier22526225273721643842481605597055980583006164061641616426576065765657676577169090697107426374263 2674263 TC7639076390 2676390 TC7835078350 2678350 TC783517860978609 2678609 TC80050869108691188000

CPT Codes Modifier88005880078801288014880168802088025880278802888029880368803788040880458809990875908769088292015923109231492340923419234292370925519255992560925909259192592925939259492595

CPT Codes Modifier93668961109615597810978119781397814989439896698967989689896999026990279907599172991739917499381993829938399384993859938699387993919939299393993949939599396993979940199402

CPT Codes Modifier994039940499408994099941199412994209942999441994429944399444994500085T0188T0189T

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 31

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierA0888A4210A4250A4252A4261A4490A4495A4500A4510A4520A4554A4575A4627A4670A6000A6413A6530A6533A6534A6535A6536A6537A6538A6539A6540A6541A6544A6549A9270A9273A9275A9276A9277A9278A9280A9281A9282A9283A9300

HCPCS Codes ModifierA9586D0120D0140D0145D0160D0170D0180D0190D0191D0273D0363D0364D0365D0366D0367D0368D0369D0370D0371D0380D0381D0382D0383D0384D0385D0386D0391D0393D0394D0395D0415D0417D0418D0425D0470D0486D1110D1120D1206

HCPCS Codes ModifierD1208D1310D1320D1330D1351D1555D2140D2150D2160D2161D2330D2331D2332D2335D2390D2391D2392D2393D2394D2410D2420D2430D2510D2520D2530D2542D2543D2544D2610D2620D2630D2642D2643D2644D2650D2651D2652D2662D2663

HCPCS Codes ModifierD2664D2710D2712D2720D2721D2722D2740D2750D2751D2752D2780D2781D2782D2783D2790D2791D2792D2794D2799D2910D2915D2920D2921D2929D2930D2931D2932D2933D2934D2940D2941D2949D2950D2951D2952D2953D2954D2955D2957

STATUS N

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 32

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierD2960D2961D2962D2971D2975D2980D2981D2982D2983D2990D3110D3120D3220D3221D3222D3230D3240D3310D3320D3330D3331D3332D3333D3346D3347D3348D3351D3352D3353D3355D3356D3357D3410D3421D3425D3426D3427D3428D3429

HCPCS Codes ModifierD3430D3431D3432D3450D3470D3910D3920D3950D4230D4231D4240D4241D4245D4249D4261D4265D4266D4267D4274D4275D4276D4320D4321D4341D4342D4910D4920D4921D4999D5110D5120D5130D5140D5211D5212D5213D5214D5225D5226

HCPCS Codes ModifierD5281D5410D5411D5421D5422D5510D5520D5610D5620D5630D5640D5650D5660D5670D5671D5710D5711D5720D5721D5730D5731D5740D5741D5750D5751D5760D5761D5810D5811D5820D5821D5850D5851D5860D5861D5862D5863D5864D5865

HCPCS Codes ModifierD5866D5867D5875D5899D5986D5991D6012D6013D6051D6053D6054D6056D6057D6058D6059D6060D6061D6062D6063D6064D6065D6066D6067D6068D6069D6070D6071D6072D6073D6074D6075D6076D6077D6078D6079D6091D6092D6093D6094

STATUS N

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 33

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierD6190D6194D6205D6210D6211D6212D6214D6240D6241D6242D6245D6250D6251D6252D6253D6545D6548D6600D6601D6602D6603D6604D6605D6606D6607D6608D6609D6610D6611D6612D6613D6614D6615D6624D6634D6710D6720D6721D6722

HCPCS Codes ModifierD6740D6750D6751D6752D6780D6781D6782D6783D6790D6791D6792D6793D6794D6930D6940D6950D6975D6980D6985D6999D7270D7272D7280D7282D7290D7292D7293D7294D7311D7871D7951D7952D7953D7963D7997D7998D8010D8020D8030

HCPCS Codes ModifierD8040D8050D8060D8070D8080D8090D8210D8220D8660D8670D8680D8690D8691D8692D8693D8694D8999D9120D9612D9910D9911D9920D9941D9942D9970D9971D9972D9973D9974D9975G0122G0122 26G0122 TCG0219G0219 26G0219 TCG0235G0235 26G0235 TC

HCPCS Codes ModifierG0252G0252 26G0252 TCG0255G0255 26G0255 TCG0282G0295G0428G9013G9014G9016G9147J3520J3535J3570J7300J7301J7302J7303J7304J8499J8515M0075M0076M0100M0300M0301P2031Q0144T4521T4522T4523T4524T4525T4526T4527T4528T4529

STATUS N

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 34

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierT4530T4531T4532T4533T4534T4535T4536T4537T4538T4539T4540T4543T4544V2025V2702V2787V2788V5008V5010V5011V5014V5020V5030V5040V5050V5060V5070V5080V5090V5095V5100V5110V5120V5130V5140V5150V5160V5170V5180

HCPCS Codes ModifierV5190V5200V5210V5220V5230V5240V5241V5242V5243V5244V5245V5246V5247V5248V5249V5250V5251V5252V5253V5254V5255V5256V5257V5258V5259V5260V5261V5262V5263V5264V5265V5266V5267V5268V5269V5270V5271V5272V5273

HCPCS Codes ModifierV5274V5275V5281V5282V5283V5284V5285V5286V5287V5288V5289V5290V5298V5336V5362V5363V5364

STATUS N

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 35Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

HCPCS Codes ModifierA4211A4212A4220A4253A4256A4258A4259A4265A4301A4305A4306A4310A4311A4312A4313A4314A4315A4316A4320A4322A4326A4327A4328A4330A4335A4338A4340A4344A4346A4351A4352A4354A4355A4356

HCPCS Codes ModifierA4357A4358A4361A4362A4364A4367A4397A4398A4399A4400A4402A4404A4455A4465A4470A4480A4556A4557A4558A4649A5051A5052A5053A5054A5055A5061A5062A5063A5071A5072A5073A5081A5082A5093

HCPCS Codes ModifierA5102A5105A5112A5113A5114A5121A5122A5126A5131A6154A6196A6197A6198A6199A6203A6204A6205A6206A6207A6208A6209A6210A6211A6212A6213A6214A6215A6216A6217A6218A6219A6220A6221A6222

HCPCS Codes ModifierA6223A6224A6228A6229A6230A6234A6235A6236A6237A6238A6239A6240A6241A6242A6243A6244A6245A6246A6247A6248A6250A6251A6252A6253A6254A6255A6256A6257A6258A6259A6260A6261A6262A6266

STATUS P Status P codes are bundled/excluded codes. There are no RVUs or payment amounts for these codes, and separate payment is not made.

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 36

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierA6402A6403A6404V2520

STATUS P

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 37Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

HCPCS Codes ModifierG8978G8979G8980G8981G8982G8983G8984G8985G8986G8987G8988G8989G8990G8991G8992G8993G8994G8995G8996G8997G8998G8999G9158G9159G9160G9161G9162G9163G9164G9165G9166G9167G9168G9169

HCPCS Codes ModifierG9170G9171G9172G9173G9174G9175G9176G9186

STATUS QStatus Q codes are therapy functional reporting codes. There are no RVUs or payment amounts for these codes, and separate payment is not made.

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 38Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

CPT Codes Modifier11055110561105711719119201192111922119501195111952119541197615775157761578815789157921582415825158261582815829158301587615877158781587917380228572286222865304003041030420

CPT Codes Modifier30430304353045032491339353394535475364683646937215382053820638240382414084040842408434084440845418204182141822418234182841830418504187041872418744413244133441354413647135

CPT Codes Modifier471364855459840598415985059851598525985559856598575986661630616356722169300699907155571555 2671555 TC7215972159 2672159 TC7322573225 2673225 TC7372573725 2673725 TC7418574185 2674185 TC7760077600 2677600 TC

CPT Codes Modifier7760577605 2677605 TC7761077610 2677610 TC7761577615 2677615 TC7762077620 2677620 TC904739047490846908479084993982969049702697545975469945599456

STATUS RStatus R codes have restricted coverage, and special instructions may apply. Refer to the CMS National Coverage Determinations (NCDs) and the CGS website and LCDs for more information.

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 39

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierA4890D0150D0240D0250D0260D0270D0272D0274D0277D0416D0421D0431D0460D0472D0473D0474D0475D0476D0477D0478D0479D0480D0481D0482D0483D0484D0485D0502D0601D0602D0603D0999D1510D1515D1520D1525D1550D1999D2970

HCPCS Codes ModifierD2999D3460D3999D4260D4263D4264D4268D4270D4273D4277D4278D4355D4381D5911D5912D5951D5983D5984D5985D5987D6052D6920D7111D7140D7210D7220D7230D7240D7241D7250D7260D7261D7283D7288D7291D7321D7511D7521D7940

HCPCS Codes ModifierD9110D9230D9248D9630D9930D9940D9950D9951D9952G0127G0128G0245G0246G0247G0248G0249G0250G0409G9148G9149G9150G9151G9152G9153G9156V5299

STATUS R

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 40Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

CPT Codes Modifier365913659236598947609476196523

STATUS TStatus T codes are only paid separately if there are no other physician services payable under the MPFS billed on the same date of service by the same provider. If any other services payable under the MPFS are billed on the same date of service by the same provider, these services are bundled into payment for the physician service.

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 41Modifier 26 is a CPT modifier, and

modifier TC is a HCPCS modifier.

CPT Codes Modifier32850339303394036415471334855050300774247742578267782688004780048800518005380061800698007480076801028010380150801528015480155801568015780158801598016080162801648016680168

CPT Codes Modifier80169801708017180172801738017480175801768017780178801808018280183801848018580186801888019080192801948019580196801978019880199802008020180202802038029980400804028040680408

CPT Codes Modifier80410804128041480415804168041780418804208042280424804268042880430804328043480435804368043880439804408100081001810028100381005810078101581020810258105081099811618120081201

CPT Codes Modifier81202812038120581206812078120881209812108121181212812138121481215812168121781220812218122281223812248122581226812278122881229812358124081241812428124381244812458125081251

STATUS X

Status X codes are statutorily excluded from coverage under the physician fee schedule. These codes represent items or services that are not included in the statutory definition of “physician services” for fee schedule purposes. There are no RVUs or payment amounts for these codes, and separate payment is not made under the physician fee schedule. Status X codes may be payable under a different fee schedule; this list includes codes that are payable under the ambulance fee schedule and clinical laboratory fee schedule.

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 42

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier812528125381254812558125681257812608126181262812638126481265812668126781268812708127581280812818128281287812908129181292812938129481295812968129781298812998130081301813028130381304813108131581316

CPT Codes Modifier813178131881319813218132281323813248132581326813308133181332813408134181342813508135581370813718137281373813748137581376813778137881379813808138181382813838140081401814028140381404814058140681407

CPT Codes Modifier814088147981504815078200082003820098201082013820168201782024820308204082042820438204482045820558207582085820888210182103821048210582106821078210882120821278212882131821358213682139821408214382145

CPT Codes Modifier821508215482157821608216382164821728217582180821908220582232822398224082247822488225282261822708227182272822748228682300823068230882310823308233182340823558236082365823708237382374823758237682378

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 43

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier823798238082382823838238482387823908239782415824358243682438824418246582480824828248582486824878248882489824918249282495825078252082523825258252882530825338254082541825428254382544825508255282553

CPT Codes Modifier825548256582570825758258582595826008260782608826108261582626826278263382634826388264682649826518265282654826568265782658826648266682668826708267182672826778267982690826938269682705827108271582725

CPT Codes Modifier827268272882731827358274282746827478275782759827608277582776827778278482785827878280082803828058281082820829308293882941829438294582946829478294882950829518295282953829558296082962829638296582975

CPT Codes Modifier829778297882979829808298583001830028300383008830098301083012830138301483015830188302083021830268303083033830368303783045830508305183055830608306583068830698307083071830808308883090831508349183497

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 44

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier834988349983500835058351683518835198352083525835278352883540835508357083582835868359383605836158362583630836318363283633836348365583661836628366383664836708369083695836988370083701837048371883719

CPT Codes Modifier837218372783735837758378583788837898380583825838358384083857838588386183864838668387283873838748387683880838838388583887839158391683918839198392183925839308393583937839458395083951839708398683987

CPT Codes Modifier839928399384022840308403584060840618406684075840788408084081840858408784100841058410684110841128411984120841268412784132841338413484135841388414084143841448414584146841508415284153841548415584156

CPT Codes Modifier841578416084163841658416684181841828420284203842068420784210842208422884233842348423584238842448425284255842608427084275842858429584300843028430584307843118431584375843768437784378843798439284402

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 45

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier844038442584430844318443284436844378443984442844438444584446844498445084460844668447884479844808448184482844848448584488844908451084512845208452584540845458455084560845778457884580845838458584586

CPT Codes Modifier845888459084591845978460084620846308468184702847038470484830849998500285004850078500885009850138501485018850258502785032850418504485045850468504885049850558513085170851758521085220852308524085244

CPT Codes Modifier852458524685247852508526085270852808529085291852928529385300853018530285303853058530685307853358533785345853478534885360853628536685370853788537985380853848538585390853978540085410854158542085421

CPT Codes Modifier854418544585460854618547585520855258553085536855408554785549855558555785576855978559885610856118561285613856358565185652856608567085675857058573085732858108599986000860018600386005860218602286023

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 46

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier860388603986060860638614086141861468614786148861528615586156861578616086161861628617186185862008621586225862268623586243862558625686277862808629486300863018630486305863088630986310863168631786318

CPT Codes Modifier863208632586327863298633186332863348633586336863378634086341863438634486352863538635586356863578635986360863618636786376863788638286384863868640386406864308643186480864818659086592865938660286603

CPT Codes Modifier866068660986611866128661586617866188661986622866258662886631866328663586638866418664486645866488665186652866538665486658866638666486665866668666886671866748667786682866848668786688866898669286694

CPT Codes Modifier866958669686698867018670286703867048670586706867078670886709867108671186713867178672086723867278672986732867358673886741867448674786750867538675686757867598676286765867688677186774867778677886780

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 47

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier867848678786788867898679086793868008680386804868058680686807868088681286813868168681786821868228682586826868288682986830868318683286833868348683586849868508686086870868808688586886868908689186900

CPT Codes Modifier869018690286904869058690686920869218692286923869278693086931869328694086941869458695086960869658697086971869728697586976869778697886985869998700187003870158704087045870468707087071870738707587076

CPT Codes Modifier870778708187084870868708887101871028710387106871078710987110871168711887140871438714787149871508715287153871588716487166871688716987172871768717787181871848718587186871878718887190871978720587206

CPT Codes Modifier872078720987210872208723087250872528725387254872558726087265872678726987270872718727287273872748727587276872778727887279872808728187283872858729087299873008730187305873208732487327873288732987332

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 48

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier873358733687337873388733987340873418735087380873858738987390873918740087420874258742787430874498745087451874708747187472874758747687477874808748187482874858748687487874908749187492874938749587496

CPT Codes Modifier874978749887500875018750287503875108751187512875158751687517875208752187522875258752687527875288752987530875318753287533875348753587536875378753887539875408754187542875508755187552875558755687557

CPT Codes Modifier875608756187562875808758187582875908759187592876208762187622876318763287633876408764187650876518765287653876608766187797877988779987800878018780287803878048780787808878098781087850878808789987900

CPT Codes Modifier879018790287903879048790587906879108791287999881308814088142881438814788148881508815288153881548815588164881658816688167881748817588230882338823588237882398824088241882458824888249882618826288263

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 49

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

CPT Codes Modifier882648826788269882718827288273882748827588280882838828588289883718837288720887388874088741887498905089051890558906089125891608919089250892518925389254892558925789258892598926089261892648926889272

CPT Codes Modifier892808928189290892918930089310893208932189322893258932989330893318933589342893438934489346893528935389354893568939890284903789064490653906549065590656906579066090661906629066490666906679066890669

CPT Codes Modifier9067090672906739068590686906879068890732907399074090743907449074690747909409098990993925589637699190991919919299360996059960699607

STATUS X

HCPCS Codes ModifierA0382A0384A0392A0394A0396A0398A0420A0422A0424A0425A0426A0427A0428A0429A0430A0431A0432A0433A0434A0435A0436A0999A4206A4207A4208A4209A4213A4215A4216A4217A4218A4221A4222A4223A4230A4231A4233A4234A4235

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 50

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierA4236A4244A4245A4246A4247A4248A4255A4257A4280A4281A4282A4283A4284A4285A4286A4290A4321A4331A4332A4333A4334A4336A4349A4353A4360A4363A4366A4368A4369A4371A4372A4373A4375A4376A4377A4378A4379A4380A4381

HCPCS Codes ModifierA4382A4383A4384A4385A4387A4388A4389A4390A4391A4392A4393A4394A4395A4396A4405A4406A4407A4408A4409A4410A4411A4412A4413A4414A4415A4416A4417A4418A4419A4420A4421A4422A4423A4424A4425A4426A4427A4428A4429

HCPCS Codes ModifierA4430A4431A4432A4433A4434A4435A4450A4452A4456A4458A4461A4463A4481A4483A4559A4561A4562A4565A4595A4600A4601A4604A4605A4606A4608A4611A4612A4613A4614A4615A4616A4617A4618A4619A4620A4623A4624A4625A4626

HCPCS Codes ModifierA4628A4629A4630A4633A4634A4635A4636A4637A4638A4639A4640A4648A4650A4651A4652A4653A4657A4660A4663A4671A4672A4673A4674A4680A4690A4706A4707A4708A4709A4714A4719A4720A4721A4722A4723A4724A4725A4726A4728

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 51

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierA4730A4736A4737A4740A4750A4755A4760A4765A4766A4770A4771A4772A4773A4774A4802A4860A4870A4911A4913A4918A4927A4928A4929A4930A4931A4932A5056A5057A5083A5120A5200A5500A5501A5503A5504A5505A5506A5507A5508

HCPCS Codes ModifierA5510A5512A5513A6010A6011A6021A6022A6023A6024A6025A6231A6232A6233A6407A6410A6411A6412A6441A6442A6443A6444A6445A6446A6447A6448A6449A6450A6451A6452A6453A6454A6455A6456A6457A6501A6502A6503A6504A6505

HCPCS Codes ModifierA6506A6507A6508A6509A6510A6511A6512A6513A6531A6532A6545A6550A7000A7001A7002A7003A7004A7005A7006A7007A7008A7009A7010A7011A7012A7013A7014A7015A7016A7017A7018A7020A7025A7026A7027A7028A7029A7030A7031

HCPCS Codes ModifierA7032A7033A7034A7035A7036A7037A7038A7039A7040A7041A7042A7043A7044A7045A7046A7047A7501A7502A7503A7504A7505A7506A7507A7508A7509A7520A7521A7522A7523A7524A7525A7526A7527A8000A8001A8002A8003A8004A9155

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 52

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierA9284A9520A9575A9576A9577A9578A9579A9581A9582A9583A9584A9585A9604A9698A9900A9901A9999G0008G0009G0010G0027G0103G0123G0129G0143G0144G0145G0147G0148G0151G0152G0153G0154G0155G0156G0173G0175G0176G0177

HCPCS Codes ModifierG0302G0303G0304G0305G0306G0307G0328G0333G0337G0378G0379G0380G0381G0382G0383G0384G0390G0410G0411G0431G0432G0433G0434G0435G3001G8907G8908G8909G8910G8911G8912G8913G8914G8915G8916G8917G8918G9001G9002

HCPCS Codes ModifierG9003G9004G9005G9006G9007G9008G9009G9010G9011G9012G9017G9018G9019G9020G9033G9034G9035G9036G9140G9143J7190J7191J7192J7193J7194J7195J7197J7198J7199J7500J7501J7504J7505J7506J7509J7510J7599P2028P2029

HCPCS Codes ModifierP2033P2038P3000P9023P9031P9032P9033P9034P9035P9036P9037P9038P9039P9040P9041P9043P9044P9045P9046P9047P9048P9050P9051P9052P9053P9054P9055P9056P9057P9058P9059P9060P9603P9604P9612P9615Q0111Q0112Q0113

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 53

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierQ0114Q0115Q0163Q0164Q0166Q0167Q0169Q0173Q0174Q0175Q0177Q0180Q0181Q1004Q1005Q2034Q2035Q2036Q2037Q2038Q2039Q3014Q4001Q4002Q4003Q4004Q4005Q4006Q4007Q4008Q4009Q4010Q4011Q4012Q4013Q4014Q4015Q4016Q4017

HCPCS Codes ModifierQ4018Q4019Q4020Q4021Q4022Q4023Q4024Q4025Q4026Q4027Q4028Q4029Q4030Q4031Q4032Q4033Q4034Q4035Q4036Q4037Q4038Q4039Q4040Q4041Q4042Q4043Q4044Q4045Q4046Q4047Q4048Q4049Q4050Q4051Q4131Q4132Q4133Q4134Q4135

HCPCS Codes ModifierQ4136V2020V2100V2101V2102V2103V2104V2105V2106V2107V2108V2109V2110V2111V2112V2113V2114V2115V2118V2121V2199V2200V2201V2202V2203V2204V2205V2206V2207V2208V2209V2210V2211V2212V2213V2214V2215V2218V2219

HCPCS Codes ModifierV2220V2221V2299V2300V2301V2302V2303V2304V2305V2306V2307V2308V2309V2310V2311V2312V2313V2314V2315V2318V2319V2320V2321V2399V2410V2430V2499V2500V2501V2502V2503V2510V2511V2512V2513V2521V2522V2523V2530

STATUS X

February 17, 2014© 2014 Copyright, CGS Administrators, LLC. PAGE 54

Bundled, Inactive, and Non-Payable Codes for 2013: Medicare Physician Fee Schedule Database

Modifier 26 is a CPT modifier, and modifier TC is a HCPCS modifier.

HCPCS Codes ModifierV2531V2599V2600V2610V2615V2623V2624V2625V2626V2627V2628V2629V2630V2631V2632V2700V2710V2715V2718V2730V2744V2745V2750V2755V2756V2760V2761V2762V2770V2780V2781V2782V2783V2784V2785V2786V2790V2797V2799

STATUS X