bluecross blueshield of tennessee commercial code bundling ... · effective date of service:...

255
Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive Component Code Code Source 80047 80048 NCCI 80047 80051 NCCI 80047 82330 NCCI 80047 82374 NCCI 80047 82435 NCCI 80047 82565 NCCI 80047 82947 NCCI 80047 84132 NCCI 80047 84295 NCCI 80047 84520 NCCI 80048 80048 BCBST 80048 80051 NCCI 80048 82310 NCCI 80048 82374 NCCI 80048 82435 NCCI 80048 82565 NCCI 80048 82947 NCCI 80048 84132 NCCI 80048 84295 NCCI 80048 84520 NCCI 80050 80050 BCBST 80051 80051 BCBST 80051 82374 NCCI 80051 82435 NCCI 80051 84132 NCCI 80051 84295 NCCI 80053 80047 NCCI 80053 80048 NCCI 80053 80051 NCCI 80053 80053 BCBST 80053 80069 NCCI 80053 80076 NCCI 80053 82040 NCCI 80053 82247 NCCI 80053 82310 NCCI 80053 82374 NCCI 80053 82435 NCCI 80053 82565 NCCI 80053 82947 NCCI 80053 84075 NCCI 80053 84132 NCCI 80053 84155 NCCI 80053 84295 NCCI 80053 84450 NCCI 80053 84460 NCCI 80053 84520 NCCI 80061 80500 NCCI Comprehensive Component Code Code Source 80061 80502 NCCI 80061 82465 NCCI 80061 83718 NCCI 80061 83721 NCCI 80061 84478 NCCI 80069 80047 NCCI 80069 80048 NCCI 80069 80051 NCCI 80069 80076 NCCI 80069 82040 NCCI 80069 82310 NCCI 80069 82374 NCCI 80069 82435 NCCI 80069 82565 NCCI 80069 82947 NCCI 80069 84100 NCCI 80069 84132 NCCI 80069 84295 NCCI 80069 84520 NCCI 80074 86705 NCCI 80074 86709 NCCI 80074 86803 NCCI 80074 87340 NCCI 80076 82040 NCCI 80076 82247 NCCI 80076 82248 NCCI 80076 84075 NCCI 80076 84155 NCCI 80076 84450 NCCI 80076 84460 NCCI 80081 85004 NCCI 80081 85007 NCCI 80081 85008 NCCI 80081 85009 NCCI 80081 85013 NCCI 80081 85014 NCCI 80081 85018 NCCI 80081 85025 NCCI 80081 85027 NCCI 80081 85032 NCCI 80081 85041 NCCI 80081 85048 NCCI 80081 85049 NCCI 80081 86592 NCCI 80081 86762 NCCI 80081 86780 NCCI 80081 86850 NCCI CPT® is a registered trademark of the American Medical Association Current Dental Terminology © 2004 American Dental Association Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis. Print Date: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 1 of 255

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Page 1: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

80047 80048 NCCI

80047 80051 NCCI

80047 82330 NCCI

80047 82374 NCCI

80047 82435 NCCI

80047 82565 NCCI

80047 82947 NCCI

80047 84132 NCCI

80047 84295 NCCI

80047 84520 NCCI

80048 80048 BCBST

80048 80051 NCCI

80048 82310 NCCI

80048 82374 NCCI

80048 82435 NCCI

80048 82565 NCCI

80048 82947 NCCI

80048 84132 NCCI

80048 84295 NCCI

80048 84520 NCCI

80050 80050 BCBST

80051 80051 BCBST

80051 82374 NCCI

80051 82435 NCCI

80051 84132 NCCI

80051 84295 NCCI

80053 80047 NCCI

80053 80048 NCCI

80053 80051 NCCI

80053 80053 BCBST

80053 80069 NCCI

80053 80076 NCCI

80053 82040 NCCI

80053 82247 NCCI

80053 82310 NCCI

80053 82374 NCCI

80053 82435 NCCI

80053 82565 NCCI

80053 82947 NCCI

80053 84075 NCCI

80053 84132 NCCI

80053 84155 NCCI

80053 84295 NCCI

80053 84450 NCCI

80053 84460 NCCI

80053 84520 NCCI

80061 80500 NCCI

Comprehensive ComponentCode Code Source

80061 80502 NCCI

80061 82465 NCCI

80061 83718 NCCI

80061 83721 NCCI

80061 84478 NCCI

80069 80047 NCCI

80069 80048 NCCI

80069 80051 NCCI

80069 80076 NCCI

80069 82040 NCCI

80069 82310 NCCI

80069 82374 NCCI

80069 82435 NCCI

80069 82565 NCCI

80069 82947 NCCI

80069 84100 NCCI

80069 84132 NCCI

80069 84295 NCCI

80069 84520 NCCI

80074 86705 NCCI

80074 86709 NCCI

80074 86803 NCCI

80074 87340 NCCI

80076 82040 NCCI

80076 82247 NCCI

80076 82248 NCCI

80076 84075 NCCI

80076 84155 NCCI

80076 84450 NCCI

80076 84460 NCCI

80081 85004 NCCI

80081 85007 NCCI

80081 85008 NCCI

80081 85009 NCCI

80081 85013 NCCI

80081 85014 NCCI

80081 85018 NCCI

80081 85025 NCCI

80081 85027 NCCI

80081 85032 NCCI

80081 85041 NCCI

80081 85048 NCCI

80081 85049 NCCI

80081 86592 NCCI

80081 86762 NCCI

80081 86780 NCCI

80081 86850 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 1 of 255

Page 2: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

80081 86900 NCCI

80081 86901 NCCI

80081 87340 NCCI

80081 87389 NCCI

80081 G0306 NCCI

80081 G0307 NCCI

80150 80150 BCBST

80152 80152 BCBST

80156 80156 BCBST

80157 80157 BCBST

80160 80160 BCBST

80162 80162 BCBST

80164 80164 BCBST

80166 80166 BCBST

80168 80168 BCBST

80170 80170 BCBST

80173 80173 BCBST

80174 80174 BCBST

80176 80176 BCBST

80178 80178 BCBST

80182 80182 BCBST

80184 80184 BCBST

80185 80185 BCBST

80186 80186 BCBST

80188 80188 BCBST

80190 80190 BCBST

80192 80190 NCCI

80192 80192 BCBST

80194 80194 BCBST

80196 80196 BCBST

80197 80197 BCBST

80198 80198 BCBST

80200 80200 BCBST

80201 80201 BCBST

80202 80202 BCBST

80299 80299 BCBST

80305 80500 NCCI

80305 80502 NCCI

80305 81000 NCCI

80305 81001 NCCI

80305 81002 NCCI

80305 81003 NCCI

80305 81005 NCCI

80305 82542 NCCI

80305 82570 NCCI

80305 83516 NCCI

80305 83518 NCCI

Comprehensive ComponentCode Code Source

80305 83519 NCCI

80305 83520 NCCI

80305 83789 NCCI

80305 83986 NCCI

80305 84156 NCCI

80305 84311 NCCI

80305 96523 NCCI

80306 80305 NCCI

80306 80500 NCCI

80306 80502 NCCI

80306 81000 NCCI

80306 81001 NCCI

80306 81002 NCCI

80306 81003 NCCI

80306 81005 NCCI

80306 82542 NCCI

80306 82570 NCCI

80306 83516 NCCI

80306 83518 NCCI

80306 83519 NCCI

80306 83520 NCCI

80306 83789 NCCI

80306 83986 NCCI

80306 84156 NCCI

80306 84311 NCCI

80306 96523 NCCI

80307 80305 NCCI

80307 80306 NCCI

80307 80500 NCCI

80307 80502 NCCI

80307 81000 NCCI

80307 81001 NCCI

80307 81002 NCCI

80307 81003 NCCI

80307 81005 NCCI

80307 82542 NCCI

80307 82570 NCCI

80307 83516 NCCI

80307 83518 NCCI

80307 83519 NCCI

80307 83520 NCCI

80307 83789 NCCI

80307 83986 NCCI

80307 84156 NCCI

80307 84311 NCCI

80307 96523 NCCI

80400 80402 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 2 of 255

Page 3: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

80400 80406 NCCI

80400 80500 NCCI

80400 80502 NCCI

80400 82533 NCCI

80402 80500 NCCI

80402 80502 NCCI

80402 82533 NCCI

80402 83498 NCCI

80406 80402 NCCI

80406 80500 NCCI

80406 80502 NCCI

80406 82533 NCCI

80406 84143 NCCI

80408 80500 NCCI

80408 80502 NCCI

80408 82088 NCCI

80408 84244 NCCI

80410 80500 NCCI

80410 80502 NCCI

80410 82308 NCCI

80412 80500 NCCI

80412 80502 NCCI

80412 82024 NCCI

80412 82533 NCCI

80414 80415 NCCI

80414 80500 NCCI

80414 80502 NCCI

80414 84403 NCCI

80415 80500 NCCI

80415 80502 NCCI

80415 82670 NCCI

80416 80500 NCCI

80416 80502 NCCI

80416 84244 NCCI

80417 80416 NCCI

80417 80500 NCCI

80417 80502 NCCI

80417 84244 NCCI

80418 80500 NCCI

80418 80502 NCCI

80418 82024 NCCI

80418 82533 NCCI

80418 83001 NCCI

80418 83002 NCCI

80418 83003 NCCI

80418 84146 NCCI

80418 84443 NCCI

Comprehensive ComponentCode Code Source

80420 80500 NCCI

80420 80502 NCCI

80420 81050 NCCI

80420 82530 NCCI

80420 82533 NCCI

80422 80424 NCCI

80422 80500 NCCI

80422 80502 NCCI

80422 82947 NCCI

80422 83525 NCCI

80424 80500 NCCI

80424 80502 NCCI

80424 82384 NCCI

80426 80500 NCCI

80426 80502 NCCI

80426 83001 NCCI

80426 83002 NCCI

80428 80500 NCCI

80428 80502 NCCI

80428 83003 NCCI

80430 80500 NCCI

80430 80502 NCCI

80430 82947 NCCI

80430 83003 NCCI

80432 80500 NCCI

80432 80502 NCCI

80432 82947 NCCI

80432 83525 NCCI

80432 84681 NCCI

80434 80435 NCCI

80434 80500 NCCI

80434 80502 NCCI

80434 82533 NCCI

80434 82947 NCCI

80435 80500 NCCI

80435 80502 NCCI

80435 82947 NCCI

80435 83003 NCCI

80436 80500 NCCI

80436 80502 NCCI

80436 82533 NCCI

80436 82634 NCCI

80438 80439 NCCI

80438 80500 NCCI

80438 80502 NCCI

80438 84443 NCCI

80439 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 3 of 255

Page 4: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

80439 80502 NCCI

80439 84443 NCCI

80500 85060 NCCI

80502 80500 NCCI

81000 81000 BCBST

81000 81002 NCCI

81000 81015 NCCI

81001 81000 NCCI

81001 81001 BCBST

81001 81002 NCCI

81001 81003 NCCI

81001 81007 NCCI

81001 81015 NCCI

81002 81007 NCCI

81002 81015 NCCI

81003 81000 NCCI

81003 81002 NCCI

81003 81007 NCCI

81003 81015 NCCI

81005 81000 NCCI

81005 81002 NCCI

81005 81003 NCCI

81005 81007 NCCI

81005 81015 NCCI

81007 81000 NCCI

81007 81015 NCCI

81007 87086 NCCI

81007 87088 NCCI

81020 81000 NCCI

81099 81099 BCBST

81161 80500 NCCI

81161 80502 NCCI

81161 84311 NCCI

81161 87140 NCCI

81161 87143 NCCI

81161 87147 NCCI

81161 87149 NCCI

81161 87150 NCCI

81161 87152 NCCI

81161 87153 NCCI

81161 87158 NCCI

81161 87470 NCCI

81161 87471 NCCI

81161 87472 NCCI

81161 87475 NCCI

81161 87476 NCCI

81161 87477 NCCI

Comprehensive ComponentCode Code Source

81161 87480 NCCI

81161 87481 NCCI

81161 87482 NCCI

81161 87483 NCCI

81161 87485 NCCI

81161 87486 NCCI

81161 87487 NCCI

81161 87490 NCCI

81161 87491 NCCI

81161 87492 NCCI

81161 87493 NCCI

81161 87495 NCCI

81161 87496 NCCI

81161 87497 NCCI

81161 87498 NCCI

81161 87500 NCCI

81161 87501 NCCI

81161 87502 NCCI

81161 87503 NCCI

81161 87505 NCCI

81161 87506 NCCI

81161 87507 NCCI

81161 87510 NCCI

81161 87511 NCCI

81161 87512 NCCI

81161 87515 NCCI

81161 87516 NCCI

81161 87517 NCCI

81161 87520 NCCI

81161 87521 NCCI

81161 87522 NCCI

81161 87525 NCCI

81161 87526 NCCI

81161 87527 NCCI

81161 87528 NCCI

81161 87529 NCCI

81161 87530 NCCI

81161 87531 NCCI

81161 87532 NCCI

81161 87533 NCCI

81161 87534 NCCI

81161 87535 NCCI

81161 87536 NCCI

81161 87537 NCCI

81161 87538 NCCI

81161 87539 NCCI

81161 87540 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 4 of 255

Page 5: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81161 87541 NCCI

81161 87542 NCCI

81161 87550 NCCI

81161 87551 NCCI

81161 87552 NCCI

81161 87555 NCCI

81161 87556 NCCI

81161 87557 NCCI

81161 87560 NCCI

81161 87561 NCCI

81161 87562 NCCI

81161 87580 NCCI

81161 87581 NCCI

81161 87582 NCCI

81161 87590 NCCI

81161 87591 NCCI

81161 87592 NCCI

81161 87623 NCCI

81161 87624 NCCI

81161 87625 NCCI

81161 87631 NCCI

81161 87632 NCCI

81161 87633 NCCI

81161 87640 NCCI

81161 87641 NCCI

81161 87650 NCCI

81161 87651 NCCI

81161 87652 NCCI

81161 87653 NCCI

81161 87660 NCCI

81161 87661 NCCI

81161 87797 NCCI

81161 87798 NCCI

81161 87799 NCCI

81161 87800 NCCI

81161 87801 NCCI

81161 88271 NCCI

81161 88272 NCCI

81161 88273 NCCI

81161 88274 NCCI

81161 88275 NCCI

81161 88291 NCCI

81161 88364 NCCI

81161 88365 NCCI

81161 88366 NCCI

81161 88367 NCCI

81161 88368 NCCI

Comprehensive ComponentCode Code Source

81161 88369 NCCI

81161 88373 NCCI

81161 88374 NCCI

81161 88377 NCCI

81161 G0476 NCCI

81162 80500 NCCI

81162 80502 NCCI

81162 81211 NCCI

81162 81213 NCCI

81162 81214 NCCI

81162 81216 NCCI

81162 84311 NCCI

81162 87140 NCCI

81162 87143 NCCI

81162 87147 NCCI

81162 87149 NCCI

81162 87150 NCCI

81162 87152 NCCI

81162 87153 NCCI

81162 87158 NCCI

81162 87470 NCCI

81162 87471 NCCI

81162 87472 NCCI

81162 87475 NCCI

81162 87476 NCCI

81162 87477 NCCI

81162 87480 NCCI

81162 87481 NCCI

81162 87482 NCCI

81162 87483 NCCI

81162 87485 NCCI

81162 87486 NCCI

81162 87487 NCCI

81162 87490 NCCI

81162 87491 NCCI

81162 87492 NCCI

81162 87493 NCCI

81162 87495 NCCI

81162 87496 NCCI

81162 87497 NCCI

81162 87498 NCCI

81162 87500 NCCI

81162 87501 NCCI

81162 87502 NCCI

81162 87503 NCCI

81162 87505 NCCI

81162 87506 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 5 of 255

Page 6: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81162 87507 NCCI

81162 87510 NCCI

81162 87511 NCCI

81162 87512 NCCI

81162 87515 NCCI

81162 87516 NCCI

81162 87517 NCCI

81162 87520 NCCI

81162 87521 NCCI

81162 87522 NCCI

81162 87525 NCCI

81162 87526 NCCI

81162 87527 NCCI

81162 87528 NCCI

81162 87529 NCCI

81162 87530 NCCI

81162 87531 NCCI

81162 87532 NCCI

81162 87533 NCCI

81162 87534 NCCI

81162 87535 NCCI

81162 87536 NCCI

81162 87537 NCCI

81162 87538 NCCI

81162 87539 NCCI

81162 87540 NCCI

81162 87541 NCCI

81162 87542 NCCI

81162 87550 NCCI

81162 87551 NCCI

81162 87552 NCCI

81162 87555 NCCI

81162 87556 NCCI

81162 87557 NCCI

81162 87560 NCCI

81162 87561 NCCI

81162 87562 NCCI

81162 87580 NCCI

81162 87581 NCCI

81162 87582 NCCI

81162 87590 NCCI

81162 87591 NCCI

81162 87592 NCCI

81162 87623 NCCI

81162 87624 NCCI

81162 87625 NCCI

81162 87631 NCCI

Comprehensive ComponentCode Code Source

81162 87632 NCCI

81162 87633 NCCI

81162 87640 NCCI

81162 87641 NCCI

81162 87650 NCCI

81162 87651 NCCI

81162 87652 NCCI

81162 87653 NCCI

81162 87660 NCCI

81162 87661 NCCI

81162 87797 NCCI

81162 87798 NCCI

81162 87799 NCCI

81162 87800 NCCI

81162 87801 NCCI

81162 88271 NCCI

81162 88272 NCCI

81162 88273 NCCI

81162 88274 NCCI

81162 88275 NCCI

81162 88291 NCCI

81162 88364 NCCI

81162 88365 NCCI

81162 88366 NCCI

81162 88367 NCCI

81162 88368 NCCI

81162 88369 NCCI

81162 88373 NCCI

81162 88374 NCCI

81162 88377 NCCI

81162 G0476 NCCI

81170 80500 NCCI

81170 80502 NCCI

81170 84311 NCCI

81170 87140 NCCI

81170 87143 NCCI

81170 87147 NCCI

81170 87149 NCCI

81170 87150 NCCI

81170 87152 NCCI

81170 87153 NCCI

81170 87158 NCCI

81170 87470 NCCI

81170 87471 NCCI

81170 87472 NCCI

81170 87475 NCCI

81170 87476 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 6 of 255

Page 7: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81170 87477 NCCI

81170 87480 NCCI

81170 87481 NCCI

81170 87482 NCCI

81170 87483 NCCI

81170 87485 NCCI

81170 87486 NCCI

81170 87487 NCCI

81170 87490 NCCI

81170 87491 NCCI

81170 87492 NCCI

81170 87493 NCCI

81170 87495 NCCI

81170 87496 NCCI

81170 87497 NCCI

81170 87498 NCCI

81170 87500 NCCI

81170 87501 NCCI

81170 87502 NCCI

81170 87503 NCCI

81170 87505 NCCI

81170 87506 NCCI

81170 87507 NCCI

81170 87510 NCCI

81170 87511 NCCI

81170 87512 NCCI

81170 87515 NCCI

81170 87516 NCCI

81170 87517 NCCI

81170 87520 NCCI

81170 87521 NCCI

81170 87522 NCCI

81170 87525 NCCI

81170 87526 NCCI

81170 87527 NCCI

81170 87528 NCCI

81170 87529 NCCI

81170 87530 NCCI

81170 87531 NCCI

81170 87532 NCCI

81170 87533 NCCI

81170 87534 NCCI

81170 87535 NCCI

81170 87536 NCCI

81170 87537 NCCI

81170 87538 NCCI

81170 87539 NCCI

Comprehensive ComponentCode Code Source

81170 87540 NCCI

81170 87541 NCCI

81170 87542 NCCI

81170 87550 NCCI

81170 87551 NCCI

81170 87552 NCCI

81170 87555 NCCI

81170 87556 NCCI

81170 87557 NCCI

81170 87560 NCCI

81170 87561 NCCI

81170 87562 NCCI

81170 87580 NCCI

81170 87581 NCCI

81170 87582 NCCI

81170 87590 NCCI

81170 87591 NCCI

81170 87592 NCCI

81170 87623 NCCI

81170 87624 NCCI

81170 87625 NCCI

81170 87631 NCCI

81170 87632 NCCI

81170 87633 NCCI

81170 87640 NCCI

81170 87641 NCCI

81170 87650 NCCI

81170 87651 NCCI

81170 87652 NCCI

81170 87653 NCCI

81170 87660 NCCI

81170 87661 NCCI

81170 87797 NCCI

81170 87798 NCCI

81170 87799 NCCI

81170 87800 NCCI

81170 87801 NCCI

81170 88271 NCCI

81170 88272 NCCI

81170 88273 NCCI

81170 88274 NCCI

81170 88275 NCCI

81170 88291 NCCI

81170 88364 NCCI

81170 88365 NCCI

81170 88366 NCCI

81170 88367 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 7 of 255

Page 8: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81170 88368 NCCI

81170 88369 NCCI

81170 88373 NCCI

81170 88374 NCCI

81170 88377 NCCI

81170 G0476 NCCI

81200 80500 NCCI

81200 80502 NCCI

81200 84311 NCCI

81200 87140 NCCI

81200 87143 NCCI

81200 87147 NCCI

81200 87149 NCCI

81200 87150 NCCI

81200 87152 NCCI

81200 87153 NCCI

81200 87158 NCCI

81200 87470 NCCI

81200 87471 NCCI

81200 87472 NCCI

81200 87475 NCCI

81200 87476 NCCI

81200 87477 NCCI

81200 87480 NCCI

81200 87481 NCCI

81200 87482 NCCI

81200 87483 NCCI

81200 87485 NCCI

81200 87486 NCCI

81200 87487 NCCI

81200 87490 NCCI

81200 87491 NCCI

81200 87492 NCCI

81200 87493 NCCI

81200 87495 NCCI

81200 87496 NCCI

81200 87497 NCCI

81200 87498 NCCI

81200 87500 NCCI

81200 87501 NCCI

81200 87502 NCCI

81200 87503 NCCI

81200 87505 NCCI

81200 87506 NCCI

81200 87507 NCCI

81200 87510 NCCI

81200 87511 NCCI

Comprehensive ComponentCode Code Source

81200 87512 NCCI

81200 87515 NCCI

81200 87516 NCCI

81200 87517 NCCI

81200 87520 NCCI

81200 87521 NCCI

81200 87522 NCCI

81200 87525 NCCI

81200 87526 NCCI

81200 87527 NCCI

81200 87528 NCCI

81200 87529 NCCI

81200 87530 NCCI

81200 87531 NCCI

81200 87532 NCCI

81200 87533 NCCI

81200 87534 NCCI

81200 87535 NCCI

81200 87536 NCCI

81200 87537 NCCI

81200 87538 NCCI

81200 87539 NCCI

81200 87540 NCCI

81200 87541 NCCI

81200 87542 NCCI

81200 87550 NCCI

81200 87551 NCCI

81200 87552 NCCI

81200 87555 NCCI

81200 87556 NCCI

81200 87557 NCCI

81200 87560 NCCI

81200 87561 NCCI

81200 87562 NCCI

81200 87580 NCCI

81200 87581 NCCI

81200 87582 NCCI

81200 87590 NCCI

81200 87591 NCCI

81200 87592 NCCI

81200 87623 NCCI

81200 87624 NCCI

81200 87625 NCCI

81200 87631 NCCI

81200 87632 NCCI

81200 87633 NCCI

81200 87640 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 8 of 255

Page 9: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81200 87641 NCCI

81200 87650 NCCI

81200 87651 NCCI

81200 87652 NCCI

81200 87653 NCCI

81200 87660 NCCI

81200 87661 NCCI

81200 87797 NCCI

81200 87798 NCCI

81200 87799 NCCI

81200 87800 NCCI

81200 87801 NCCI

81200 88271 NCCI

81200 88272 NCCI

81200 88273 NCCI

81200 88274 NCCI

81200 88275 NCCI

81200 88291 NCCI

81200 88364 NCCI

81200 88365 NCCI

81200 88366 NCCI

81200 88367 NCCI

81200 88368 NCCI

81200 88369 NCCI

81200 88373 NCCI

81200 88374 NCCI

81200 88377 NCCI

81200 G0476 NCCI

81201 80500 NCCI

81201 80502 NCCI

81201 81202 NCCI

81201 81203 NCCI

81201 84311 NCCI

81201 87140 NCCI

81201 87143 NCCI

81201 87147 NCCI

81201 87149 NCCI

81201 87150 NCCI

81201 87152 NCCI

81201 87153 NCCI

81201 87158 NCCI

81201 87470 NCCI

81201 87471 NCCI

81201 87472 NCCI

81201 87475 NCCI

81201 87476 NCCI

81201 87477 NCCI

Comprehensive ComponentCode Code Source

81201 87480 NCCI

81201 87481 NCCI

81201 87482 NCCI

81201 87483 NCCI

81201 87485 NCCI

81201 87486 NCCI

81201 87487 NCCI

81201 87490 NCCI

81201 87491 NCCI

81201 87492 NCCI

81201 87493 NCCI

81201 87495 NCCI

81201 87496 NCCI

81201 87497 NCCI

81201 87498 NCCI

81201 87500 NCCI

81201 87501 NCCI

81201 87502 NCCI

81201 87503 NCCI

81201 87505 NCCI

81201 87506 NCCI

81201 87507 NCCI

81201 87510 NCCI

81201 87511 NCCI

81201 87512 NCCI

81201 87515 NCCI

81201 87516 NCCI

81201 87517 NCCI

81201 87520 NCCI

81201 87521 NCCI

81201 87522 NCCI

81201 87525 NCCI

81201 87526 NCCI

81201 87527 NCCI

81201 87528 NCCI

81201 87529 NCCI

81201 87530 NCCI

81201 87531 NCCI

81201 87532 NCCI

81201 87533 NCCI

81201 87534 NCCI

81201 87535 NCCI

81201 87536 NCCI

81201 87537 NCCI

81201 87538 NCCI

81201 87539 NCCI

81201 87540 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 9 of 255

Page 10: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81201 87541 NCCI

81201 87542 NCCI

81201 87550 NCCI

81201 87551 NCCI

81201 87552 NCCI

81201 87555 NCCI

81201 87556 NCCI

81201 87557 NCCI

81201 87560 NCCI

81201 87561 NCCI

81201 87562 NCCI

81201 87580 NCCI

81201 87581 NCCI

81201 87582 NCCI

81201 87590 NCCI

81201 87591 NCCI

81201 87592 NCCI

81201 87623 NCCI

81201 87624 NCCI

81201 87625 NCCI

81201 87631 NCCI

81201 87632 NCCI

81201 87633 NCCI

81201 87640 NCCI

81201 87641 NCCI

81201 87650 NCCI

81201 87651 NCCI

81201 87652 NCCI

81201 87653 NCCI

81201 87660 NCCI

81201 87661 NCCI

81201 87797 NCCI

81201 87798 NCCI

81201 87799 NCCI

81201 87800 NCCI

81201 87801 NCCI

81201 88271 NCCI

81201 88272 NCCI

81201 88273 NCCI

81201 88274 NCCI

81201 88275 NCCI

81201 88291 NCCI

81201 88364 NCCI

81201 88365 NCCI

81201 88366 NCCI

81201 88367 NCCI

81201 88368 NCCI

Comprehensive ComponentCode Code Source

81201 88369 NCCI

81201 88373 NCCI

81201 88374 NCCI

81201 88377 NCCI

81201 G0476 NCCI

81202 80500 NCCI

81202 80502 NCCI

81202 81203 NCCI

81202 84311 NCCI

81202 87140 NCCI

81202 87143 NCCI

81202 87147 NCCI

81202 87149 NCCI

81202 87150 NCCI

81202 87152 NCCI

81202 87153 NCCI

81202 87158 NCCI

81202 87470 NCCI

81202 87471 NCCI

81202 87472 NCCI

81202 87475 NCCI

81202 87476 NCCI

81202 87477 NCCI

81202 87480 NCCI

81202 87481 NCCI

81202 87482 NCCI

81202 87483 NCCI

81202 87485 NCCI

81202 87486 NCCI

81202 87487 NCCI

81202 87490 NCCI

81202 87491 NCCI

81202 87492 NCCI

81202 87493 NCCI

81202 87495 NCCI

81202 87496 NCCI

81202 87497 NCCI

81202 87498 NCCI

81202 87500 NCCI

81202 87501 NCCI

81202 87502 NCCI

81202 87503 NCCI

81202 87505 NCCI

81202 87506 NCCI

81202 87507 NCCI

81202 87510 NCCI

81202 87511 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 10 of 255

Page 11: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81202 87512 NCCI

81202 87515 NCCI

81202 87516 NCCI

81202 87517 NCCI

81202 87520 NCCI

81202 87521 NCCI

81202 87522 NCCI

81202 87525 NCCI

81202 87526 NCCI

81202 87527 NCCI

81202 87528 NCCI

81202 87529 NCCI

81202 87530 NCCI

81202 87531 NCCI

81202 87532 NCCI

81202 87533 NCCI

81202 87534 NCCI

81202 87535 NCCI

81202 87536 NCCI

81202 87537 NCCI

81202 87538 NCCI

81202 87539 NCCI

81202 87540 NCCI

81202 87541 NCCI

81202 87542 NCCI

81202 87550 NCCI

81202 87551 NCCI

81202 87552 NCCI

81202 87555 NCCI

81202 87556 NCCI

81202 87557 NCCI

81202 87560 NCCI

81202 87561 NCCI

81202 87562 NCCI

81202 87580 NCCI

81202 87581 NCCI

81202 87582 NCCI

81202 87590 NCCI

81202 87591 NCCI

81202 87592 NCCI

81202 87623 NCCI

81202 87624 NCCI

81202 87625 NCCI

81202 87631 NCCI

81202 87632 NCCI

81202 87633 NCCI

81202 87640 NCCI

Comprehensive ComponentCode Code Source

81202 87641 NCCI

81202 87650 NCCI

81202 87651 NCCI

81202 87652 NCCI

81202 87653 NCCI

81202 87660 NCCI

81202 87661 NCCI

81202 87797 NCCI

81202 87798 NCCI

81202 87799 NCCI

81202 87800 NCCI

81202 87801 NCCI

81202 88271 NCCI

81202 88272 NCCI

81202 88273 NCCI

81202 88274 NCCI

81202 88275 NCCI

81202 88291 NCCI

81202 88364 NCCI

81202 88365 NCCI

81202 88366 NCCI

81202 88367 NCCI

81202 88368 NCCI

81202 88369 NCCI

81202 88373 NCCI

81202 88374 NCCI

81202 88377 NCCI

81202 G0476 NCCI

81203 80500 NCCI

81203 80502 NCCI

81203 84311 NCCI

81203 87140 NCCI

81203 87143 NCCI

81203 87147 NCCI

81203 87149 NCCI

81203 87150 NCCI

81203 87152 NCCI

81203 87153 NCCI

81203 87158 NCCI

81203 87470 NCCI

81203 87471 NCCI

81203 87472 NCCI

81203 87475 NCCI

81203 87476 NCCI

81203 87477 NCCI

81203 87480 NCCI

81203 87481 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 11 of 255

Page 12: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81203 87482 NCCI

81203 87483 NCCI

81203 87485 NCCI

81203 87486 NCCI

81203 87487 NCCI

81203 87490 NCCI

81203 87491 NCCI

81203 87492 NCCI

81203 87493 NCCI

81203 87495 NCCI

81203 87496 NCCI

81203 87497 NCCI

81203 87498 NCCI

81203 87500 NCCI

81203 87501 NCCI

81203 87502 NCCI

81203 87503 NCCI

81203 87505 NCCI

81203 87506 NCCI

81203 87507 NCCI

81203 87510 NCCI

81203 87511 NCCI

81203 87512 NCCI

81203 87515 NCCI

81203 87516 NCCI

81203 87517 NCCI

81203 87520 NCCI

81203 87521 NCCI

81203 87522 NCCI

81203 87525 NCCI

81203 87526 NCCI

81203 87527 NCCI

81203 87528 NCCI

81203 87529 NCCI

81203 87530 NCCI

81203 87531 NCCI

81203 87532 NCCI

81203 87533 NCCI

81203 87534 NCCI

81203 87535 NCCI

81203 87536 NCCI

81203 87537 NCCI

81203 87538 NCCI

81203 87539 NCCI

81203 87540 NCCI

81203 87541 NCCI

81203 87542 NCCI

Comprehensive ComponentCode Code Source

81203 87550 NCCI

81203 87551 NCCI

81203 87552 NCCI

81203 87555 NCCI

81203 87556 NCCI

81203 87557 NCCI

81203 87560 NCCI

81203 87561 NCCI

81203 87562 NCCI

81203 87580 NCCI

81203 87581 NCCI

81203 87582 NCCI

81203 87590 NCCI

81203 87591 NCCI

81203 87592 NCCI

81203 87623 NCCI

81203 87624 NCCI

81203 87625 NCCI

81203 87631 NCCI

81203 87632 NCCI

81203 87633 NCCI

81203 87640 NCCI

81203 87641 NCCI

81203 87650 NCCI

81203 87651 NCCI

81203 87652 NCCI

81203 87653 NCCI

81203 87660 NCCI

81203 87661 NCCI

81203 87797 NCCI

81203 87798 NCCI

81203 87799 NCCI

81203 87800 NCCI

81203 87801 NCCI

81203 88271 NCCI

81203 88272 NCCI

81203 88273 NCCI

81203 88274 NCCI

81203 88275 NCCI

81203 88291 NCCI

81203 88364 NCCI

81203 88365 NCCI

81203 88366 NCCI

81203 88367 NCCI

81203 88368 NCCI

81203 88369 NCCI

81203 88373 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 12 of 255

Page 13: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81203 88374 NCCI

81203 88377 NCCI

81203 G0476 NCCI

81205 80500 NCCI

81205 80502 NCCI

81205 84311 NCCI

81205 87140 NCCI

81205 87143 NCCI

81205 87147 NCCI

81205 87149 NCCI

81205 87150 NCCI

81205 87152 NCCI

81205 87153 NCCI

81205 87158 NCCI

81205 87470 NCCI

81205 87471 NCCI

81205 87472 NCCI

81205 87475 NCCI

81205 87476 NCCI

81205 87477 NCCI

81205 87480 NCCI

81205 87481 NCCI

81205 87482 NCCI

81205 87483 NCCI

81205 87485 NCCI

81205 87486 NCCI

81205 87487 NCCI

81205 87490 NCCI

81205 87491 NCCI

81205 87492 NCCI

81205 87493 NCCI

81205 87495 NCCI

81205 87496 NCCI

81205 87497 NCCI

81205 87498 NCCI

81205 87500 NCCI

81205 87501 NCCI

81205 87502 NCCI

81205 87503 NCCI

81205 87505 NCCI

81205 87506 NCCI

81205 87507 NCCI

81205 87510 NCCI

81205 87511 NCCI

81205 87512 NCCI

81205 87515 NCCI

81205 87516 NCCI

Comprehensive ComponentCode Code Source

81205 87517 NCCI

81205 87520 NCCI

81205 87521 NCCI

81205 87522 NCCI

81205 87525 NCCI

81205 87526 NCCI

81205 87527 NCCI

81205 87528 NCCI

81205 87529 NCCI

81205 87530 NCCI

81205 87531 NCCI

81205 87532 NCCI

81205 87533 NCCI

81205 87534 NCCI

81205 87535 NCCI

81205 87536 NCCI

81205 87537 NCCI

81205 87538 NCCI

81205 87539 NCCI

81205 87540 NCCI

81205 87541 NCCI

81205 87542 NCCI

81205 87550 NCCI

81205 87551 NCCI

81205 87552 NCCI

81205 87555 NCCI

81205 87556 NCCI

81205 87557 NCCI

81205 87560 NCCI

81205 87561 NCCI

81205 87562 NCCI

81205 87580 NCCI

81205 87581 NCCI

81205 87582 NCCI

81205 87590 NCCI

81205 87591 NCCI

81205 87592 NCCI

81205 87623 NCCI

81205 87624 NCCI

81205 87625 NCCI

81205 87631 NCCI

81205 87632 NCCI

81205 87633 NCCI

81205 87640 NCCI

81205 87641 NCCI

81205 87650 NCCI

81205 87651 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 13 of 255

Page 14: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81205 87652 NCCI

81205 87653 NCCI

81205 87660 NCCI

81205 87661 NCCI

81205 87797 NCCI

81205 87798 NCCI

81205 87799 NCCI

81205 87800 NCCI

81205 87801 NCCI

81205 88271 NCCI

81205 88272 NCCI

81205 88273 NCCI

81205 88274 NCCI

81205 88275 NCCI

81205 88291 NCCI

81205 88364 NCCI

81205 88365 NCCI

81205 88366 NCCI

81205 88367 NCCI

81205 88368 NCCI

81205 88369 NCCI

81205 88373 NCCI

81205 88374 NCCI

81205 88377 NCCI

81205 G0476 NCCI

81206 80500 NCCI

81206 80502 NCCI

81206 84311 NCCI

81206 87140 NCCI

81206 87143 NCCI

81206 87147 NCCI

81206 87149 NCCI

81206 87150 NCCI

81206 87152 NCCI

81206 87153 NCCI

81206 87158 NCCI

81206 87470 NCCI

81206 87471 NCCI

81206 87472 NCCI

81206 87475 NCCI

81206 87476 NCCI

81206 87477 NCCI

81206 87480 NCCI

81206 87481 NCCI

81206 87482 NCCI

81206 87483 NCCI

81206 87485 NCCI

Comprehensive ComponentCode Code Source

81206 87486 NCCI

81206 87487 NCCI

81206 87490 NCCI

81206 87491 NCCI

81206 87492 NCCI

81206 87493 NCCI

81206 87495 NCCI

81206 87496 NCCI

81206 87497 NCCI

81206 87498 NCCI

81206 87500 NCCI

81206 87501 NCCI

81206 87502 NCCI

81206 87503 NCCI

81206 87505 NCCI

81206 87506 NCCI

81206 87507 NCCI

81206 87510 NCCI

81206 87511 NCCI

81206 87512 NCCI

81206 87515 NCCI

81206 87516 NCCI

81206 87517 NCCI

81206 87520 NCCI

81206 87521 NCCI

81206 87522 NCCI

81206 87525 NCCI

81206 87526 NCCI

81206 87527 NCCI

81206 87528 NCCI

81206 87529 NCCI

81206 87530 NCCI

81206 87531 NCCI

81206 87532 NCCI

81206 87533 NCCI

81206 87534 NCCI

81206 87535 NCCI

81206 87536 NCCI

81206 87537 NCCI

81206 87538 NCCI

81206 87539 NCCI

81206 87540 NCCI

81206 87541 NCCI

81206 87542 NCCI

81206 87550 NCCI

81206 87551 NCCI

81206 87552 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 14 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81206 87555 NCCI

81206 87556 NCCI

81206 87557 NCCI

81206 87560 NCCI

81206 87561 NCCI

81206 87562 NCCI

81206 87580 NCCI

81206 87581 NCCI

81206 87582 NCCI

81206 87590 NCCI

81206 87591 NCCI

81206 87592 NCCI

81206 87623 NCCI

81206 87624 NCCI

81206 87625 NCCI

81206 87631 NCCI

81206 87632 NCCI

81206 87633 NCCI

81206 87640 NCCI

81206 87641 NCCI

81206 87650 NCCI

81206 87651 NCCI

81206 87652 NCCI

81206 87653 NCCI

81206 87660 NCCI

81206 87661 NCCI

81206 87797 NCCI

81206 87798 NCCI

81206 87799 NCCI

81206 87800 NCCI

81206 87801 NCCI

81206 88271 NCCI

81206 88272 NCCI

81206 88273 NCCI

81206 88274 NCCI

81206 88275 NCCI

81206 88291 NCCI

81206 88364 NCCI

81206 88365 NCCI

81206 88366 NCCI

81206 88367 NCCI

81206 88368 NCCI

81206 88369 NCCI

81206 88373 NCCI

81206 88374 NCCI

81206 88377 NCCI

81206 G0476 NCCI

Comprehensive ComponentCode Code Source

81207 80500 NCCI

81207 80502 NCCI

81207 84311 NCCI

81207 87140 NCCI

81207 87143 NCCI

81207 87147 NCCI

81207 87149 NCCI

81207 87150 NCCI

81207 87152 NCCI

81207 87153 NCCI

81207 87158 NCCI

81207 87470 NCCI

81207 87471 NCCI

81207 87472 NCCI

81207 87475 NCCI

81207 87476 NCCI

81207 87477 NCCI

81207 87480 NCCI

81207 87481 NCCI

81207 87482 NCCI

81207 87483 NCCI

81207 87485 NCCI

81207 87486 NCCI

81207 87487 NCCI

81207 87490 NCCI

81207 87491 NCCI

81207 87492 NCCI

81207 87493 NCCI

81207 87495 NCCI

81207 87496 NCCI

81207 87497 NCCI

81207 87498 NCCI

81207 87500 NCCI

81207 87501 NCCI

81207 87502 NCCI

81207 87503 NCCI

81207 87505 NCCI

81207 87506 NCCI

81207 87507 NCCI

81207 87510 NCCI

81207 87511 NCCI

81207 87512 NCCI

81207 87515 NCCI

81207 87516 NCCI

81207 87517 NCCI

81207 87520 NCCI

81207 87521 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 15 of 255

Page 16: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81207 87522 NCCI

81207 87525 NCCI

81207 87526 NCCI

81207 87527 NCCI

81207 87528 NCCI

81207 87529 NCCI

81207 87530 NCCI

81207 87531 NCCI

81207 87532 NCCI

81207 87533 NCCI

81207 87534 NCCI

81207 87535 NCCI

81207 87536 NCCI

81207 87537 NCCI

81207 87538 NCCI

81207 87539 NCCI

81207 87540 NCCI

81207 87541 NCCI

81207 87542 NCCI

81207 87550 NCCI

81207 87551 NCCI

81207 87552 NCCI

81207 87555 NCCI

81207 87556 NCCI

81207 87557 NCCI

81207 87560 NCCI

81207 87561 NCCI

81207 87562 NCCI

81207 87580 NCCI

81207 87581 NCCI

81207 87582 NCCI

81207 87590 NCCI

81207 87591 NCCI

81207 87592 NCCI

81207 87623 NCCI

81207 87624 NCCI

81207 87625 NCCI

81207 87631 NCCI

81207 87632 NCCI

81207 87633 NCCI

81207 87640 NCCI

81207 87641 NCCI

81207 87650 NCCI

81207 87651 NCCI

81207 87652 NCCI

81207 87653 NCCI

81207 87660 NCCI

Comprehensive ComponentCode Code Source

81207 87661 NCCI

81207 87797 NCCI

81207 87798 NCCI

81207 87799 NCCI

81207 87800 NCCI

81207 87801 NCCI

81207 88271 NCCI

81207 88272 NCCI

81207 88273 NCCI

81207 88274 NCCI

81207 88275 NCCI

81207 88291 NCCI

81207 88364 NCCI

81207 88365 NCCI

81207 88366 NCCI

81207 88367 NCCI

81207 88368 NCCI

81207 88369 NCCI

81207 88373 NCCI

81207 88374 NCCI

81207 88377 NCCI

81207 G0476 NCCI

81208 80500 NCCI

81208 80502 NCCI

81208 84311 NCCI

81208 87140 NCCI

81208 87143 NCCI

81208 87147 NCCI

81208 87149 NCCI

81208 87150 NCCI

81208 87152 NCCI

81208 87153 NCCI

81208 87158 NCCI

81208 87470 NCCI

81208 87471 NCCI

81208 87472 NCCI

81208 87475 NCCI

81208 87476 NCCI

81208 87477 NCCI

81208 87480 NCCI

81208 87481 NCCI

81208 87482 NCCI

81208 87483 NCCI

81208 87485 NCCI

81208 87486 NCCI

81208 87487 NCCI

81208 87490 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 16 of 255

Page 17: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81208 87491 NCCI

81208 87492 NCCI

81208 87493 NCCI

81208 87495 NCCI

81208 87496 NCCI

81208 87497 NCCI

81208 87498 NCCI

81208 87500 NCCI

81208 87501 NCCI

81208 87502 NCCI

81208 87503 NCCI

81208 87505 NCCI

81208 87506 NCCI

81208 87507 NCCI

81208 87510 NCCI

81208 87511 NCCI

81208 87512 NCCI

81208 87515 NCCI

81208 87516 NCCI

81208 87517 NCCI

81208 87520 NCCI

81208 87521 NCCI

81208 87522 NCCI

81208 87525 NCCI

81208 87526 NCCI

81208 87527 NCCI

81208 87528 NCCI

81208 87529 NCCI

81208 87530 NCCI

81208 87531 NCCI

81208 87532 NCCI

81208 87533 NCCI

81208 87534 NCCI

81208 87535 NCCI

81208 87536 NCCI

81208 87537 NCCI

81208 87538 NCCI

81208 87539 NCCI

81208 87540 NCCI

81208 87541 NCCI

81208 87542 NCCI

81208 87550 NCCI

81208 87551 NCCI

81208 87552 NCCI

81208 87555 NCCI

81208 87556 NCCI

81208 87557 NCCI

Comprehensive ComponentCode Code Source

81208 87560 NCCI

81208 87561 NCCI

81208 87562 NCCI

81208 87580 NCCI

81208 87581 NCCI

81208 87582 NCCI

81208 87590 NCCI

81208 87591 NCCI

81208 87592 NCCI

81208 87623 NCCI

81208 87624 NCCI

81208 87625 NCCI

81208 87631 NCCI

81208 87632 NCCI

81208 87633 NCCI

81208 87640 NCCI

81208 87641 NCCI

81208 87650 NCCI

81208 87651 NCCI

81208 87652 NCCI

81208 87653 NCCI

81208 87660 NCCI

81208 87661 NCCI

81208 87797 NCCI

81208 87798 NCCI

81208 87799 NCCI

81208 87800 NCCI

81208 87801 NCCI

81208 88271 NCCI

81208 88272 NCCI

81208 88273 NCCI

81208 88274 NCCI

81208 88275 NCCI

81208 88291 NCCI

81208 88364 NCCI

81208 88365 NCCI

81208 88366 NCCI

81208 88367 NCCI

81208 88368 NCCI

81208 88369 NCCI

81208 88373 NCCI

81208 88374 NCCI

81208 88377 NCCI

81208 G0476 NCCI

81209 80500 NCCI

81209 80502 NCCI

81209 84311 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 17 of 255

Page 18: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81209 87140 NCCI

81209 87143 NCCI

81209 87147 NCCI

81209 87149 NCCI

81209 87150 NCCI

81209 87152 NCCI

81209 87153 NCCI

81209 87158 NCCI

81209 87470 NCCI

81209 87471 NCCI

81209 87472 NCCI

81209 87475 NCCI

81209 87476 NCCI

81209 87477 NCCI

81209 87480 NCCI

81209 87481 NCCI

81209 87482 NCCI

81209 87483 NCCI

81209 87485 NCCI

81209 87486 NCCI

81209 87487 NCCI

81209 87490 NCCI

81209 87491 NCCI

81209 87492 NCCI

81209 87493 NCCI

81209 87495 NCCI

81209 87496 NCCI

81209 87497 NCCI

81209 87498 NCCI

81209 87500 NCCI

81209 87501 NCCI

81209 87502 NCCI

81209 87503 NCCI

81209 87505 NCCI

81209 87506 NCCI

81209 87507 NCCI

81209 87510 NCCI

81209 87511 NCCI

81209 87512 NCCI

81209 87515 NCCI

81209 87516 NCCI

81209 87517 NCCI

81209 87520 NCCI

81209 87521 NCCI

81209 87522 NCCI

81209 87525 NCCI

81209 87526 NCCI

Comprehensive ComponentCode Code Source

81209 87527 NCCI

81209 87528 NCCI

81209 87529 NCCI

81209 87530 NCCI

81209 87531 NCCI

81209 87532 NCCI

81209 87533 NCCI

81209 87534 NCCI

81209 87535 NCCI

81209 87536 NCCI

81209 87537 NCCI

81209 87538 NCCI

81209 87539 NCCI

81209 87540 NCCI

81209 87541 NCCI

81209 87542 NCCI

81209 87550 NCCI

81209 87551 NCCI

81209 87552 NCCI

81209 87555 NCCI

81209 87556 NCCI

81209 87557 NCCI

81209 87560 NCCI

81209 87561 NCCI

81209 87562 NCCI

81209 87580 NCCI

81209 87581 NCCI

81209 87582 NCCI

81209 87590 NCCI

81209 87591 NCCI

81209 87592 NCCI

81209 87623 NCCI

81209 87624 NCCI

81209 87625 NCCI

81209 87631 NCCI

81209 87632 NCCI

81209 87633 NCCI

81209 87640 NCCI

81209 87641 NCCI

81209 87650 NCCI

81209 87651 NCCI

81209 87652 NCCI

81209 87653 NCCI

81209 87660 NCCI

81209 87661 NCCI

81209 87797 NCCI

81209 87798 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 18 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81209 87799 NCCI

81209 87800 NCCI

81209 87801 NCCI

81209 88271 NCCI

81209 88272 NCCI

81209 88273 NCCI

81209 88274 NCCI

81209 88275 NCCI

81209 88291 NCCI

81209 88364 NCCI

81209 88365 NCCI

81209 88366 NCCI

81209 88367 NCCI

81209 88368 NCCI

81209 88369 NCCI

81209 88373 NCCI

81209 88374 NCCI

81209 88377 NCCI

81209 G0476 NCCI

81210 80500 NCCI

81210 80502 NCCI

81210 84311 NCCI

81210 87140 NCCI

81210 87143 NCCI

81210 87147 NCCI

81210 87149 NCCI

81210 87150 NCCI

81210 87152 NCCI

81210 87153 NCCI

81210 87158 NCCI

81210 87470 NCCI

81210 87471 NCCI

81210 87472 NCCI

81210 87475 NCCI

81210 87476 NCCI

81210 87477 NCCI

81210 87480 NCCI

81210 87481 NCCI

81210 87482 NCCI

81210 87483 NCCI

81210 87485 NCCI

81210 87486 NCCI

81210 87487 NCCI

81210 87490 NCCI

81210 87491 NCCI

81210 87492 NCCI

81210 87493 NCCI

Comprehensive ComponentCode Code Source

81210 87495 NCCI

81210 87496 NCCI

81210 87497 NCCI

81210 87498 NCCI

81210 87500 NCCI

81210 87501 NCCI

81210 87502 NCCI

81210 87503 NCCI

81210 87505 NCCI

81210 87506 NCCI

81210 87507 NCCI

81210 87510 NCCI

81210 87511 NCCI

81210 87512 NCCI

81210 87515 NCCI

81210 87516 NCCI

81210 87517 NCCI

81210 87520 NCCI

81210 87521 NCCI

81210 87522 NCCI

81210 87525 NCCI

81210 87526 NCCI

81210 87527 NCCI

81210 87528 NCCI

81210 87529 NCCI

81210 87530 NCCI

81210 87531 NCCI

81210 87532 NCCI

81210 87533 NCCI

81210 87534 NCCI

81210 87535 NCCI

81210 87536 NCCI

81210 87537 NCCI

81210 87538 NCCI

81210 87539 NCCI

81210 87540 NCCI

81210 87541 NCCI

81210 87542 NCCI

81210 87550 NCCI

81210 87551 NCCI

81210 87552 NCCI

81210 87555 NCCI

81210 87556 NCCI

81210 87557 NCCI

81210 87560 NCCI

81210 87561 NCCI

81210 87562 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 19 of 255

Page 20: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81210 87580 NCCI

81210 87581 NCCI

81210 87582 NCCI

81210 87590 NCCI

81210 87591 NCCI

81210 87592 NCCI

81210 87623 NCCI

81210 87624 NCCI

81210 87625 NCCI

81210 87631 NCCI

81210 87632 NCCI

81210 87633 NCCI

81210 87640 NCCI

81210 87641 NCCI

81210 87650 NCCI

81210 87651 NCCI

81210 87652 NCCI

81210 87653 NCCI

81210 87660 NCCI

81210 87661 NCCI

81210 87797 NCCI

81210 87798 NCCI

81210 87799 NCCI

81210 87800 NCCI

81210 87801 NCCI

81210 88271 NCCI

81210 88272 NCCI

81210 88273 NCCI

81210 88274 NCCI

81210 88275 NCCI

81210 88291 NCCI

81210 88364 NCCI

81210 88365 NCCI

81210 88366 NCCI

81210 88367 NCCI

81210 88368 NCCI

81210 88369 NCCI

81210 88373 NCCI

81210 88374 NCCI

81210 88377 NCCI

81210 G0476 NCCI

81211 80500 NCCI

81211 80502 NCCI

81211 81212 NCCI

81211 81213 NCCI

81211 81214 NCCI

81211 81215 NCCI

Comprehensive ComponentCode Code Source

81211 81216 NCCI

81211 81217 NCCI

81211 84311 NCCI

81211 87140 NCCI

81211 87143 NCCI

81211 87147 NCCI

81211 87149 NCCI

81211 87150 NCCI

81211 87152 NCCI

81211 87153 NCCI

81211 87158 NCCI

81211 87470 NCCI

81211 87471 NCCI

81211 87472 NCCI

81211 87475 NCCI

81211 87476 NCCI

81211 87477 NCCI

81211 87480 NCCI

81211 87481 NCCI

81211 87482 NCCI

81211 87483 NCCI

81211 87485 NCCI

81211 87486 NCCI

81211 87487 NCCI

81211 87490 NCCI

81211 87491 NCCI

81211 87492 NCCI

81211 87493 NCCI

81211 87495 NCCI

81211 87496 NCCI

81211 87497 NCCI

81211 87498 NCCI

81211 87500 NCCI

81211 87501 NCCI

81211 87502 NCCI

81211 87503 NCCI

81211 87505 NCCI

81211 87506 NCCI

81211 87507 NCCI

81211 87510 NCCI

81211 87511 NCCI

81211 87512 NCCI

81211 87515 NCCI

81211 87516 NCCI

81211 87517 NCCI

81211 87520 NCCI

81211 87521 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 20 of 255

Page 21: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81211 87522 NCCI

81211 87525 NCCI

81211 87526 NCCI

81211 87527 NCCI

81211 87528 NCCI

81211 87529 NCCI

81211 87530 NCCI

81211 87531 NCCI

81211 87532 NCCI

81211 87533 NCCI

81211 87534 NCCI

81211 87535 NCCI

81211 87536 NCCI

81211 87537 NCCI

81211 87538 NCCI

81211 87539 NCCI

81211 87540 NCCI

81211 87541 NCCI

81211 87542 NCCI

81211 87550 NCCI

81211 87551 NCCI

81211 87552 NCCI

81211 87555 NCCI

81211 87556 NCCI

81211 87557 NCCI

81211 87560 NCCI

81211 87561 NCCI

81211 87562 NCCI

81211 87580 NCCI

81211 87581 NCCI

81211 87582 NCCI

81211 87590 NCCI

81211 87591 NCCI

81211 87592 NCCI

81211 87623 NCCI

81211 87624 NCCI

81211 87625 NCCI

81211 87631 NCCI

81211 87632 NCCI

81211 87633 NCCI

81211 87640 NCCI

81211 87641 NCCI

81211 87650 NCCI

81211 87651 NCCI

81211 87652 NCCI

81211 87653 NCCI

81211 87660 NCCI

Comprehensive ComponentCode Code Source

81211 87661 NCCI

81211 87797 NCCI

81211 87798 NCCI

81211 87799 NCCI

81211 87800 NCCI

81211 87801 NCCI

81211 88271 NCCI

81211 88272 NCCI

81211 88273 NCCI

81211 88274 NCCI

81211 88275 NCCI

81211 88291 NCCI

81211 88364 NCCI

81211 88365 NCCI

81211 88366 NCCI

81211 88367 NCCI

81211 88368 NCCI

81211 88369 NCCI

81211 88373 NCCI

81211 88374 NCCI

81211 88377 NCCI

81211 G0476 NCCI

81212 80500 NCCI

81212 80502 NCCI

81212 81213 NCCI

81212 81214 NCCI

81212 81215 NCCI

81212 81216 NCCI

81212 81217 NCCI

81212 84311 NCCI

81212 87140 NCCI

81212 87143 NCCI

81212 87147 NCCI

81212 87149 NCCI

81212 87150 NCCI

81212 87152 NCCI

81212 87153 NCCI

81212 87158 NCCI

81212 87470 NCCI

81212 87471 NCCI

81212 87472 NCCI

81212 87475 NCCI

81212 87476 NCCI

81212 87477 NCCI

81212 87480 NCCI

81212 87481 NCCI

81212 87482 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 21 of 255

Page 22: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81212 87483 NCCI

81212 87485 NCCI

81212 87486 NCCI

81212 87487 NCCI

81212 87490 NCCI

81212 87491 NCCI

81212 87492 NCCI

81212 87493 NCCI

81212 87495 NCCI

81212 87496 NCCI

81212 87497 NCCI

81212 87498 NCCI

81212 87500 NCCI

81212 87501 NCCI

81212 87502 NCCI

81212 87503 NCCI

81212 87505 NCCI

81212 87506 NCCI

81212 87507 NCCI

81212 87510 NCCI

81212 87511 NCCI

81212 87512 NCCI

81212 87515 NCCI

81212 87516 NCCI

81212 87517 NCCI

81212 87520 NCCI

81212 87521 NCCI

81212 87522 NCCI

81212 87525 NCCI

81212 87526 NCCI

81212 87527 NCCI

81212 87528 NCCI

81212 87529 NCCI

81212 87530 NCCI

81212 87531 NCCI

81212 87532 NCCI

81212 87533 NCCI

81212 87534 NCCI

81212 87535 NCCI

81212 87536 NCCI

81212 87537 NCCI

81212 87538 NCCI

81212 87539 NCCI

81212 87540 NCCI

81212 87541 NCCI

81212 87542 NCCI

81212 87550 NCCI

Comprehensive ComponentCode Code Source

81212 87551 NCCI

81212 87552 NCCI

81212 87555 NCCI

81212 87556 NCCI

81212 87557 NCCI

81212 87560 NCCI

81212 87561 NCCI

81212 87562 NCCI

81212 87580 NCCI

81212 87581 NCCI

81212 87582 NCCI

81212 87590 NCCI

81212 87591 NCCI

81212 87592 NCCI

81212 87623 NCCI

81212 87624 NCCI

81212 87625 NCCI

81212 87631 NCCI

81212 87632 NCCI

81212 87633 NCCI

81212 87640 NCCI

81212 87641 NCCI

81212 87650 NCCI

81212 87651 NCCI

81212 87652 NCCI

81212 87653 NCCI

81212 87660 NCCI

81212 87661 NCCI

81212 87797 NCCI

81212 87798 NCCI

81212 87799 NCCI

81212 87800 NCCI

81212 87801 NCCI

81212 88271 NCCI

81212 88272 NCCI

81212 88273 NCCI

81212 88274 NCCI

81212 88275 NCCI

81212 88291 NCCI

81212 88364 NCCI

81212 88365 NCCI

81212 88366 NCCI

81212 88367 NCCI

81212 88368 NCCI

81212 88369 NCCI

81212 88373 NCCI

81212 88374 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 22 of 255

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Comprehensive ComponentCode Code Source

81212 88377 NCCI

81212 G0476 NCCI

81213 80500 NCCI

81213 80502 NCCI

81213 81214 NCCI

81213 81215 NCCI

81213 81216 NCCI

81213 81217 NCCI

81213 84311 NCCI

81213 87140 NCCI

81213 87143 NCCI

81213 87147 NCCI

81213 87149 NCCI

81213 87150 NCCI

81213 87152 NCCI

81213 87153 NCCI

81213 87158 NCCI

81213 87470 NCCI

81213 87471 NCCI

81213 87472 NCCI

81213 87475 NCCI

81213 87476 NCCI

81213 87477 NCCI

81213 87480 NCCI

81213 87481 NCCI

81213 87482 NCCI

81213 87483 NCCI

81213 87485 NCCI

81213 87486 NCCI

81213 87487 NCCI

81213 87490 NCCI

81213 87491 NCCI

81213 87492 NCCI

81213 87493 NCCI

81213 87495 NCCI

81213 87496 NCCI

81213 87497 NCCI

81213 87498 NCCI

81213 87500 NCCI

81213 87501 NCCI

81213 87502 NCCI

81213 87503 NCCI

81213 87505 NCCI

81213 87506 NCCI

81213 87507 NCCI

81213 87510 NCCI

81213 87511 NCCI

Comprehensive ComponentCode Code Source

81213 87512 NCCI

81213 87515 NCCI

81213 87516 NCCI

81213 87517 NCCI

81213 87520 NCCI

81213 87521 NCCI

81213 87522 NCCI

81213 87525 NCCI

81213 87526 NCCI

81213 87527 NCCI

81213 87528 NCCI

81213 87529 NCCI

81213 87530 NCCI

81213 87531 NCCI

81213 87532 NCCI

81213 87533 NCCI

81213 87534 NCCI

81213 87535 NCCI

81213 87536 NCCI

81213 87537 NCCI

81213 87538 NCCI

81213 87539 NCCI

81213 87540 NCCI

81213 87541 NCCI

81213 87542 NCCI

81213 87550 NCCI

81213 87551 NCCI

81213 87552 NCCI

81213 87555 NCCI

81213 87556 NCCI

81213 87557 NCCI

81213 87560 NCCI

81213 87561 NCCI

81213 87562 NCCI

81213 87580 NCCI

81213 87581 NCCI

81213 87582 NCCI

81213 87590 NCCI

81213 87591 NCCI

81213 87592 NCCI

81213 87623 NCCI

81213 87624 NCCI

81213 87625 NCCI

81213 87631 NCCI

81213 87632 NCCI

81213 87633 NCCI

81213 87640 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 23 of 255

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Comprehensive ComponentCode Code Source

81213 87641 NCCI

81213 87650 NCCI

81213 87651 NCCI

81213 87652 NCCI

81213 87653 NCCI

81213 87660 NCCI

81213 87661 NCCI

81213 87797 NCCI

81213 87798 NCCI

81213 87799 NCCI

81213 87800 NCCI

81213 87801 NCCI

81213 88271 NCCI

81213 88272 NCCI

81213 88273 NCCI

81213 88274 NCCI

81213 88275 NCCI

81213 88291 NCCI

81213 88364 NCCI

81213 88365 NCCI

81213 88366 NCCI

81213 88367 NCCI

81213 88368 NCCI

81213 88369 NCCI

81213 88373 NCCI

81213 88374 NCCI

81213 88377 NCCI

81213 G0476 NCCI

81214 80500 NCCI

81214 80502 NCCI

81214 81215 NCCI

81214 81216 NCCI

81214 81217 NCCI

81214 84311 NCCI

81214 87140 NCCI

81214 87143 NCCI

81214 87147 NCCI

81214 87149 NCCI

81214 87150 NCCI

81214 87152 NCCI

81214 87153 NCCI

81214 87158 NCCI

81214 87470 NCCI

81214 87471 NCCI

81214 87472 NCCI

81214 87475 NCCI

81214 87476 NCCI

Comprehensive ComponentCode Code Source

81214 87477 NCCI

81214 87480 NCCI

81214 87481 NCCI

81214 87482 NCCI

81214 87483 NCCI

81214 87485 NCCI

81214 87486 NCCI

81214 87487 NCCI

81214 87490 NCCI

81214 87491 NCCI

81214 87492 NCCI

81214 87493 NCCI

81214 87495 NCCI

81214 87496 NCCI

81214 87497 NCCI

81214 87498 NCCI

81214 87500 NCCI

81214 87501 NCCI

81214 87502 NCCI

81214 87503 NCCI

81214 87505 NCCI

81214 87506 NCCI

81214 87507 NCCI

81214 87510 NCCI

81214 87511 NCCI

81214 87512 NCCI

81214 87515 NCCI

81214 87516 NCCI

81214 87517 NCCI

81214 87520 NCCI

81214 87521 NCCI

81214 87522 NCCI

81214 87525 NCCI

81214 87526 NCCI

81214 87527 NCCI

81214 87528 NCCI

81214 87529 NCCI

81214 87530 NCCI

81214 87531 NCCI

81214 87532 NCCI

81214 87533 NCCI

81214 87534 NCCI

81214 87535 NCCI

81214 87536 NCCI

81214 87537 NCCI

81214 87538 NCCI

81214 87539 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 24 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81214 87540 NCCI

81214 87541 NCCI

81214 87542 NCCI

81214 87550 NCCI

81214 87551 NCCI

81214 87552 NCCI

81214 87555 NCCI

81214 87556 NCCI

81214 87557 NCCI

81214 87560 NCCI

81214 87561 NCCI

81214 87562 NCCI

81214 87580 NCCI

81214 87581 NCCI

81214 87582 NCCI

81214 87590 NCCI

81214 87591 NCCI

81214 87592 NCCI

81214 87623 NCCI

81214 87624 NCCI

81214 87625 NCCI

81214 87631 NCCI

81214 87632 NCCI

81214 87633 NCCI

81214 87640 NCCI

81214 87641 NCCI

81214 87650 NCCI

81214 87651 NCCI

81214 87652 NCCI

81214 87653 NCCI

81214 87660 NCCI

81214 87661 NCCI

81214 87797 NCCI

81214 87798 NCCI

81214 87799 NCCI

81214 87800 NCCI

81214 87801 NCCI

81214 88271 NCCI

81214 88272 NCCI

81214 88273 NCCI

81214 88274 NCCI

81214 88275 NCCI

81214 88291 NCCI

81214 88364 NCCI

81214 88365 NCCI

81214 88366 NCCI

81214 88367 NCCI

Comprehensive ComponentCode Code Source

81214 88368 NCCI

81214 88369 NCCI

81214 88373 NCCI

81214 88374 NCCI

81214 88377 NCCI

81214 G0476 NCCI

81215 80500 NCCI

81215 80502 NCCI

81215 81216 NCCI

81215 81217 NCCI

81215 84311 NCCI

81215 87140 NCCI

81215 87143 NCCI

81215 87147 NCCI

81215 87149 NCCI

81215 87150 NCCI

81215 87152 NCCI

81215 87153 NCCI

81215 87158 NCCI

81215 87470 NCCI

81215 87471 NCCI

81215 87472 NCCI

81215 87475 NCCI

81215 87476 NCCI

81215 87477 NCCI

81215 87480 NCCI

81215 87481 NCCI

81215 87482 NCCI

81215 87483 NCCI

81215 87485 NCCI

81215 87486 NCCI

81215 87487 NCCI

81215 87490 NCCI

81215 87491 NCCI

81215 87492 NCCI

81215 87493 NCCI

81215 87495 NCCI

81215 87496 NCCI

81215 87497 NCCI

81215 87498 NCCI

81215 87500 NCCI

81215 87501 NCCI

81215 87502 NCCI

81215 87503 NCCI

81215 87505 NCCI

81215 87506 NCCI

81215 87507 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 25 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81215 87510 NCCI

81215 87511 NCCI

81215 87512 NCCI

81215 87515 NCCI

81215 87516 NCCI

81215 87517 NCCI

81215 87520 NCCI

81215 87521 NCCI

81215 87522 NCCI

81215 87525 NCCI

81215 87526 NCCI

81215 87527 NCCI

81215 87528 NCCI

81215 87529 NCCI

81215 87530 NCCI

81215 87531 NCCI

81215 87532 NCCI

81215 87533 NCCI

81215 87534 NCCI

81215 87535 NCCI

81215 87536 NCCI

81215 87537 NCCI

81215 87538 NCCI

81215 87539 NCCI

81215 87540 NCCI

81215 87541 NCCI

81215 87542 NCCI

81215 87550 NCCI

81215 87551 NCCI

81215 87552 NCCI

81215 87555 NCCI

81215 87556 NCCI

81215 87557 NCCI

81215 87560 NCCI

81215 87561 NCCI

81215 87562 NCCI

81215 87580 NCCI

81215 87581 NCCI

81215 87582 NCCI

81215 87590 NCCI

81215 87591 NCCI

81215 87592 NCCI

81215 87623 NCCI

81215 87624 NCCI

81215 87625 NCCI

81215 87631 NCCI

81215 87632 NCCI

Comprehensive ComponentCode Code Source

81215 87633 NCCI

81215 87640 NCCI

81215 87641 NCCI

81215 87650 NCCI

81215 87651 NCCI

81215 87652 NCCI

81215 87653 NCCI

81215 87660 NCCI

81215 87661 NCCI

81215 87797 NCCI

81215 87798 NCCI

81215 87799 NCCI

81215 87800 NCCI

81215 87801 NCCI

81215 88271 NCCI

81215 88272 NCCI

81215 88273 NCCI

81215 88274 NCCI

81215 88275 NCCI

81215 88291 NCCI

81215 88364 NCCI

81215 88365 NCCI

81215 88366 NCCI

81215 88367 NCCI

81215 88368 NCCI

81215 88369 NCCI

81215 88373 NCCI

81215 88374 NCCI

81215 88377 NCCI

81215 G0476 NCCI

81216 80500 NCCI

81216 80502 NCCI

81216 81217 NCCI

81216 84311 NCCI

81216 87140 NCCI

81216 87143 NCCI

81216 87147 NCCI

81216 87149 NCCI

81216 87150 NCCI

81216 87152 NCCI

81216 87153 NCCI

81216 87158 NCCI

81216 87470 NCCI

81216 87471 NCCI

81216 87472 NCCI

81216 87475 NCCI

81216 87476 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 26 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81216 87477 NCCI

81216 87480 NCCI

81216 87481 NCCI

81216 87482 NCCI

81216 87483 NCCI

81216 87485 NCCI

81216 87486 NCCI

81216 87487 NCCI

81216 87490 NCCI

81216 87491 NCCI

81216 87492 NCCI

81216 87493 NCCI

81216 87495 NCCI

81216 87496 NCCI

81216 87497 NCCI

81216 87498 NCCI

81216 87500 NCCI

81216 87501 NCCI

81216 87502 NCCI

81216 87503 NCCI

81216 87505 NCCI

81216 87506 NCCI

81216 87507 NCCI

81216 87510 NCCI

81216 87511 NCCI

81216 87512 NCCI

81216 87515 NCCI

81216 87516 NCCI

81216 87517 NCCI

81216 87520 NCCI

81216 87521 NCCI

81216 87522 NCCI

81216 87525 NCCI

81216 87526 NCCI

81216 87527 NCCI

81216 87528 NCCI

81216 87529 NCCI

81216 87530 NCCI

81216 87531 NCCI

81216 87532 NCCI

81216 87533 NCCI

81216 87534 NCCI

81216 87535 NCCI

81216 87536 NCCI

81216 87537 NCCI

81216 87538 NCCI

81216 87539 NCCI

Comprehensive ComponentCode Code Source

81216 87540 NCCI

81216 87541 NCCI

81216 87542 NCCI

81216 87550 NCCI

81216 87551 NCCI

81216 87552 NCCI

81216 87555 NCCI

81216 87556 NCCI

81216 87557 NCCI

81216 87560 NCCI

81216 87561 NCCI

81216 87562 NCCI

81216 87580 NCCI

81216 87581 NCCI

81216 87582 NCCI

81216 87590 NCCI

81216 87591 NCCI

81216 87592 NCCI

81216 87623 NCCI

81216 87624 NCCI

81216 87625 NCCI

81216 87631 NCCI

81216 87632 NCCI

81216 87633 NCCI

81216 87640 NCCI

81216 87641 NCCI

81216 87650 NCCI

81216 87651 NCCI

81216 87652 NCCI

81216 87653 NCCI

81216 87660 NCCI

81216 87661 NCCI

81216 87797 NCCI

81216 87798 NCCI

81216 87799 NCCI

81216 87800 NCCI

81216 87801 NCCI

81216 88271 NCCI

81216 88272 NCCI

81216 88273 NCCI

81216 88274 NCCI

81216 88275 NCCI

81216 88291 NCCI

81216 88364 NCCI

81216 88365 NCCI

81216 88366 NCCI

81216 88367 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 27 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81216 88368 NCCI

81216 88369 NCCI

81216 88373 NCCI

81216 88374 NCCI

81216 88377 NCCI

81216 G0476 NCCI

81217 80500 NCCI

81217 80502 NCCI

81217 84311 NCCI

81217 87140 NCCI

81217 87143 NCCI

81217 87147 NCCI

81217 87149 NCCI

81217 87150 NCCI

81217 87152 NCCI

81217 87153 NCCI

81217 87158 NCCI

81217 87470 NCCI

81217 87471 NCCI

81217 87472 NCCI

81217 87475 NCCI

81217 87476 NCCI

81217 87477 NCCI

81217 87480 NCCI

81217 87481 NCCI

81217 87482 NCCI

81217 87483 NCCI

81217 87485 NCCI

81217 87486 NCCI

81217 87487 NCCI

81217 87490 NCCI

81217 87491 NCCI

81217 87492 NCCI

81217 87493 NCCI

81217 87495 NCCI

81217 87496 NCCI

81217 87497 NCCI

81217 87498 NCCI

81217 87500 NCCI

81217 87501 NCCI

81217 87502 NCCI

81217 87503 NCCI

81217 87505 NCCI

81217 87506 NCCI

81217 87507 NCCI

81217 87510 NCCI

81217 87511 NCCI

Comprehensive ComponentCode Code Source

81217 87512 NCCI

81217 87515 NCCI

81217 87516 NCCI

81217 87517 NCCI

81217 87520 NCCI

81217 87521 NCCI

81217 87522 NCCI

81217 87525 NCCI

81217 87526 NCCI

81217 87527 NCCI

81217 87528 NCCI

81217 87529 NCCI

81217 87530 NCCI

81217 87531 NCCI

81217 87532 NCCI

81217 87533 NCCI

81217 87534 NCCI

81217 87535 NCCI

81217 87536 NCCI

81217 87537 NCCI

81217 87538 NCCI

81217 87539 NCCI

81217 87540 NCCI

81217 87541 NCCI

81217 87542 NCCI

81217 87550 NCCI

81217 87551 NCCI

81217 87552 NCCI

81217 87555 NCCI

81217 87556 NCCI

81217 87557 NCCI

81217 87560 NCCI

81217 87561 NCCI

81217 87562 NCCI

81217 87580 NCCI

81217 87581 NCCI

81217 87582 NCCI

81217 87590 NCCI

81217 87591 NCCI

81217 87592 NCCI

81217 87623 NCCI

81217 87624 NCCI

81217 87625 NCCI

81217 87631 NCCI

81217 87632 NCCI

81217 87633 NCCI

81217 87640 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 28 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81217 87641 NCCI

81217 87650 NCCI

81217 87651 NCCI

81217 87652 NCCI

81217 87653 NCCI

81217 87660 NCCI

81217 87661 NCCI

81217 87797 NCCI

81217 87798 NCCI

81217 87799 NCCI

81217 87800 NCCI

81217 87801 NCCI

81217 88271 NCCI

81217 88272 NCCI

81217 88273 NCCI

81217 88274 NCCI

81217 88275 NCCI

81217 88291 NCCI

81217 88364 NCCI

81217 88365 NCCI

81217 88366 NCCI

81217 88367 NCCI

81217 88368 NCCI

81217 88369 NCCI

81217 88373 NCCI

81217 88374 NCCI

81217 88377 NCCI

81217 G0476 NCCI

81218 80500 NCCI

81218 80502 NCCI

81218 84311 NCCI

81218 87140 NCCI

81218 87143 NCCI

81218 87147 NCCI

81218 87149 NCCI

81218 87150 NCCI

81218 87152 NCCI

81218 87153 NCCI

81218 87158 NCCI

81218 87470 NCCI

81218 87471 NCCI

81218 87472 NCCI

81218 87475 NCCI

81218 87476 NCCI

81218 87477 NCCI

81218 87480 NCCI

81218 87481 NCCI

Comprehensive ComponentCode Code Source

81218 87482 NCCI

81218 87483 NCCI

81218 87485 NCCI

81218 87486 NCCI

81218 87487 NCCI

81218 87490 NCCI

81218 87491 NCCI

81218 87492 NCCI

81218 87493 NCCI

81218 87495 NCCI

81218 87496 NCCI

81218 87497 NCCI

81218 87498 NCCI

81218 87500 NCCI

81218 87501 NCCI

81218 87502 NCCI

81218 87503 NCCI

81218 87505 NCCI

81218 87506 NCCI

81218 87507 NCCI

81218 87510 NCCI

81218 87511 NCCI

81218 87512 NCCI

81218 87515 NCCI

81218 87516 NCCI

81218 87517 NCCI

81218 87520 NCCI

81218 87521 NCCI

81218 87522 NCCI

81218 87525 NCCI

81218 87526 NCCI

81218 87527 NCCI

81218 87528 NCCI

81218 87529 NCCI

81218 87530 NCCI

81218 87531 NCCI

81218 87532 NCCI

81218 87533 NCCI

81218 87534 NCCI

81218 87535 NCCI

81218 87536 NCCI

81218 87537 NCCI

81218 87538 NCCI

81218 87539 NCCI

81218 87540 NCCI

81218 87541 NCCI

81218 87542 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 29 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81218 87550 NCCI

81218 87551 NCCI

81218 87552 NCCI

81218 87555 NCCI

81218 87556 NCCI

81218 87557 NCCI

81218 87560 NCCI

81218 87561 NCCI

81218 87562 NCCI

81218 87580 NCCI

81218 87581 NCCI

81218 87582 NCCI

81218 87590 NCCI

81218 87591 NCCI

81218 87592 NCCI

81218 87623 NCCI

81218 87624 NCCI

81218 87625 NCCI

81218 87631 NCCI

81218 87632 NCCI

81218 87633 NCCI

81218 87640 NCCI

81218 87641 NCCI

81218 87650 NCCI

81218 87651 NCCI

81218 87652 NCCI

81218 87653 NCCI

81218 87660 NCCI

81218 87661 NCCI

81218 87797 NCCI

81218 87798 NCCI

81218 87799 NCCI

81218 87800 NCCI

81218 87801 NCCI

81218 88271 NCCI

81218 88272 NCCI

81218 88273 NCCI

81218 88274 NCCI

81218 88275 NCCI

81218 88291 NCCI

81218 88364 NCCI

81218 88365 NCCI

81218 88366 NCCI

81218 88367 NCCI

81218 88368 NCCI

81218 88369 NCCI

81218 88373 NCCI

Comprehensive ComponentCode Code Source

81218 88374 NCCI

81218 88377 NCCI

81218 G0476 NCCI

81219 80500 NCCI

81219 80502 NCCI

81219 84311 NCCI

81219 87140 NCCI

81219 87143 NCCI

81219 87147 NCCI

81219 87149 NCCI

81219 87150 NCCI

81219 87152 NCCI

81219 87153 NCCI

81219 87158 NCCI

81219 87470 NCCI

81219 87471 NCCI

81219 87472 NCCI

81219 87475 NCCI

81219 87476 NCCI

81219 87477 NCCI

81219 87480 NCCI

81219 87481 NCCI

81219 87482 NCCI

81219 87483 NCCI

81219 87485 NCCI

81219 87486 NCCI

81219 87487 NCCI

81219 87490 NCCI

81219 87491 NCCI

81219 87492 NCCI

81219 87493 NCCI

81219 87495 NCCI

81219 87496 NCCI

81219 87497 NCCI

81219 87498 NCCI

81219 87500 NCCI

81219 87501 NCCI

81219 87502 NCCI

81219 87503 NCCI

81219 87505 NCCI

81219 87506 NCCI

81219 87507 NCCI

81219 87510 NCCI

81219 87511 NCCI

81219 87512 NCCI

81219 87515 NCCI

81219 87516 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 30 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81219 87517 NCCI

81219 87520 NCCI

81219 87521 NCCI

81219 87522 NCCI

81219 87525 NCCI

81219 87526 NCCI

81219 87527 NCCI

81219 87528 NCCI

81219 87529 NCCI

81219 87530 NCCI

81219 87531 NCCI

81219 87532 NCCI

81219 87533 NCCI

81219 87534 NCCI

81219 87535 NCCI

81219 87536 NCCI

81219 87537 NCCI

81219 87538 NCCI

81219 87539 NCCI

81219 87540 NCCI

81219 87541 NCCI

81219 87542 NCCI

81219 87550 NCCI

81219 87551 NCCI

81219 87552 NCCI

81219 87555 NCCI

81219 87556 NCCI

81219 87557 NCCI

81219 87560 NCCI

81219 87561 NCCI

81219 87562 NCCI

81219 87580 NCCI

81219 87581 NCCI

81219 87582 NCCI

81219 87590 NCCI

81219 87591 NCCI

81219 87592 NCCI

81219 87623 NCCI

81219 87624 NCCI

81219 87625 NCCI

81219 87631 NCCI

81219 87632 NCCI

81219 87633 NCCI

81219 87640 NCCI

81219 87641 NCCI

81219 87650 NCCI

81219 87651 NCCI

Comprehensive ComponentCode Code Source

81219 87652 NCCI

81219 87653 NCCI

81219 87660 NCCI

81219 87661 NCCI

81219 87797 NCCI

81219 87798 NCCI

81219 87799 NCCI

81219 87800 NCCI

81219 87801 NCCI

81219 88271 NCCI

81219 88272 NCCI

81219 88273 NCCI

81219 88274 NCCI

81219 88275 NCCI

81219 88291 NCCI

81219 88364 NCCI

81219 88365 NCCI

81219 88366 NCCI

81219 88367 NCCI

81219 88368 NCCI

81219 88369 NCCI

81219 88373 NCCI

81219 88374 NCCI

81219 88377 NCCI

81219 G0476 NCCI

81220 80500 NCCI

81220 80502 NCCI

81220 81221 NCCI

81220 81222 NCCI

81220 84311 NCCI

81220 87140 NCCI

81220 87143 NCCI

81220 87147 NCCI

81220 87149 NCCI

81220 87150 NCCI

81220 87152 NCCI

81220 87153 NCCI

81220 87158 NCCI

81220 87470 NCCI

81220 87471 NCCI

81220 87472 NCCI

81220 87475 NCCI

81220 87476 NCCI

81220 87477 NCCI

81220 87480 NCCI

81220 87481 NCCI

81220 87482 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 31 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81220 87483 NCCI

81220 87485 NCCI

81220 87486 NCCI

81220 87487 NCCI

81220 87490 NCCI

81220 87491 NCCI

81220 87492 NCCI

81220 87493 NCCI

81220 87495 NCCI

81220 87496 NCCI

81220 87497 NCCI

81220 87498 NCCI

81220 87500 NCCI

81220 87501 NCCI

81220 87502 NCCI

81220 87503 NCCI

81220 87505 NCCI

81220 87506 NCCI

81220 87507 NCCI

81220 87510 NCCI

81220 87511 NCCI

81220 87512 NCCI

81220 87515 NCCI

81220 87516 NCCI

81220 87517 NCCI

81220 87520 NCCI

81220 87521 NCCI

81220 87522 NCCI

81220 87525 NCCI

81220 87526 NCCI

81220 87527 NCCI

81220 87528 NCCI

81220 87529 NCCI

81220 87530 NCCI

81220 87531 NCCI

81220 87532 NCCI

81220 87533 NCCI

81220 87534 NCCI

81220 87535 NCCI

81220 87536 NCCI

81220 87537 NCCI

81220 87538 NCCI

81220 87539 NCCI

81220 87540 NCCI

81220 87541 NCCI

81220 87542 NCCI

81220 87550 NCCI

Comprehensive ComponentCode Code Source

81220 87551 NCCI

81220 87552 NCCI

81220 87555 NCCI

81220 87556 NCCI

81220 87557 NCCI

81220 87560 NCCI

81220 87561 NCCI

81220 87562 NCCI

81220 87580 NCCI

81220 87581 NCCI

81220 87582 NCCI

81220 87590 NCCI

81220 87591 NCCI

81220 87592 NCCI

81220 87623 NCCI

81220 87624 NCCI

81220 87625 NCCI

81220 87631 NCCI

81220 87632 NCCI

81220 87633 NCCI

81220 87640 NCCI

81220 87641 NCCI

81220 87650 NCCI

81220 87651 NCCI

81220 87652 NCCI

81220 87653 NCCI

81220 87660 NCCI

81220 87661 NCCI

81220 87797 NCCI

81220 87798 NCCI

81220 87799 NCCI

81220 87800 NCCI

81220 87801 NCCI

81220 88271 NCCI

81220 88272 NCCI

81220 88273 NCCI

81220 88274 NCCI

81220 88275 NCCI

81220 88291 NCCI

81220 88364 NCCI

81220 88365 NCCI

81220 88366 NCCI

81220 88367 NCCI

81220 88368 NCCI

81220 88369 NCCI

81220 88373 NCCI

81220 88374 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 32 of 255

Page 33: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81220 88377 NCCI

81220 G0476 NCCI

81221 80500 NCCI

81221 80502 NCCI

81221 81222 NCCI

81221 84311 NCCI

81221 87140 NCCI

81221 87143 NCCI

81221 87147 NCCI

81221 87149 NCCI

81221 87150 NCCI

81221 87152 NCCI

81221 87153 NCCI

81221 87158 NCCI

81221 87470 NCCI

81221 87471 NCCI

81221 87472 NCCI

81221 87475 NCCI

81221 87476 NCCI

81221 87477 NCCI

81221 87480 NCCI

81221 87481 NCCI

81221 87482 NCCI

81221 87483 NCCI

81221 87485 NCCI

81221 87486 NCCI

81221 87487 NCCI

81221 87490 NCCI

81221 87491 NCCI

81221 87492 NCCI

81221 87493 NCCI

81221 87495 NCCI

81221 87496 NCCI

81221 87497 NCCI

81221 87498 NCCI

81221 87500 NCCI

81221 87501 NCCI

81221 87502 NCCI

81221 87503 NCCI

81221 87505 NCCI

81221 87506 NCCI

81221 87507 NCCI

81221 87510 NCCI

81221 87511 NCCI

81221 87512 NCCI

81221 87515 NCCI

81221 87516 NCCI

Comprehensive ComponentCode Code Source

81221 87517 NCCI

81221 87520 NCCI

81221 87521 NCCI

81221 87522 NCCI

81221 87525 NCCI

81221 87526 NCCI

81221 87527 NCCI

81221 87528 NCCI

81221 87529 NCCI

81221 87530 NCCI

81221 87531 NCCI

81221 87532 NCCI

81221 87533 NCCI

81221 87534 NCCI

81221 87535 NCCI

81221 87536 NCCI

81221 87537 NCCI

81221 87538 NCCI

81221 87539 NCCI

81221 87540 NCCI

81221 87541 NCCI

81221 87542 NCCI

81221 87550 NCCI

81221 87551 NCCI

81221 87552 NCCI

81221 87555 NCCI

81221 87556 NCCI

81221 87557 NCCI

81221 87560 NCCI

81221 87561 NCCI

81221 87562 NCCI

81221 87580 NCCI

81221 87581 NCCI

81221 87582 NCCI

81221 87590 NCCI

81221 87591 NCCI

81221 87592 NCCI

81221 87623 NCCI

81221 87624 NCCI

81221 87625 NCCI

81221 87631 NCCI

81221 87632 NCCI

81221 87633 NCCI

81221 87640 NCCI

81221 87641 NCCI

81221 87650 NCCI

81221 87651 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 33 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81221 87652 NCCI

81221 87653 NCCI

81221 87660 NCCI

81221 87661 NCCI

81221 87797 NCCI

81221 87798 NCCI

81221 87799 NCCI

81221 87800 NCCI

81221 87801 NCCI

81221 88271 NCCI

81221 88272 NCCI

81221 88273 NCCI

81221 88274 NCCI

81221 88275 NCCI

81221 88291 NCCI

81221 88364 NCCI

81221 88365 NCCI

81221 88366 NCCI

81221 88367 NCCI

81221 88368 NCCI

81221 88369 NCCI

81221 88373 NCCI

81221 88374 NCCI

81221 88377 NCCI

81221 G0476 NCCI

81222 80500 NCCI

81222 80502 NCCI

81222 84311 NCCI

81222 87140 NCCI

81222 87143 NCCI

81222 87147 NCCI

81222 87149 NCCI

81222 87150 NCCI

81222 87152 NCCI

81222 87153 NCCI

81222 87158 NCCI

81222 87470 NCCI

81222 87471 NCCI

81222 87472 NCCI

81222 87475 NCCI

81222 87476 NCCI

81222 87477 NCCI

81222 87480 NCCI

81222 87481 NCCI

81222 87482 NCCI

81222 87483 NCCI

81222 87485 NCCI

Comprehensive ComponentCode Code Source

81222 87486 NCCI

81222 87487 NCCI

81222 87490 NCCI

81222 87491 NCCI

81222 87492 NCCI

81222 87493 NCCI

81222 87495 NCCI

81222 87496 NCCI

81222 87497 NCCI

81222 87498 NCCI

81222 87500 NCCI

81222 87501 NCCI

81222 87502 NCCI

81222 87503 NCCI

81222 87505 NCCI

81222 87506 NCCI

81222 87507 NCCI

81222 87510 NCCI

81222 87511 NCCI

81222 87512 NCCI

81222 87515 NCCI

81222 87516 NCCI

81222 87517 NCCI

81222 87520 NCCI

81222 87521 NCCI

81222 87522 NCCI

81222 87525 NCCI

81222 87526 NCCI

81222 87527 NCCI

81222 87528 NCCI

81222 87529 NCCI

81222 87530 NCCI

81222 87531 NCCI

81222 87532 NCCI

81222 87533 NCCI

81222 87534 NCCI

81222 87535 NCCI

81222 87536 NCCI

81222 87537 NCCI

81222 87538 NCCI

81222 87539 NCCI

81222 87540 NCCI

81222 87541 NCCI

81222 87542 NCCI

81222 87550 NCCI

81222 87551 NCCI

81222 87552 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 34 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81222 87555 NCCI

81222 87556 NCCI

81222 87557 NCCI

81222 87560 NCCI

81222 87561 NCCI

81222 87562 NCCI

81222 87580 NCCI

81222 87581 NCCI

81222 87582 NCCI

81222 87590 NCCI

81222 87591 NCCI

81222 87592 NCCI

81222 87623 NCCI

81222 87624 NCCI

81222 87625 NCCI

81222 87631 NCCI

81222 87632 NCCI

81222 87633 NCCI

81222 87640 NCCI

81222 87641 NCCI

81222 87650 NCCI

81222 87651 NCCI

81222 87652 NCCI

81222 87653 NCCI

81222 87660 NCCI

81222 87661 NCCI

81222 87797 NCCI

81222 87798 NCCI

81222 87799 NCCI

81222 87800 NCCI

81222 87801 NCCI

81222 88271 NCCI

81222 88272 NCCI

81222 88273 NCCI

81222 88274 NCCI

81222 88275 NCCI

81222 88291 NCCI

81222 88364 NCCI

81222 88365 NCCI

81222 88366 NCCI

81222 88367 NCCI

81222 88368 NCCI

81222 88369 NCCI

81222 88373 NCCI

81222 88374 NCCI

81222 88377 NCCI

81222 G0476 NCCI

Comprehensive ComponentCode Code Source

81223 80500 NCCI

81223 80502 NCCI

81223 81220 NCCI

81223 81221 NCCI

81223 81222 NCCI

81223 84311 NCCI

81223 87140 NCCI

81223 87143 NCCI

81223 87147 NCCI

81223 87149 NCCI

81223 87150 NCCI

81223 87152 NCCI

81223 87153 NCCI

81223 87158 NCCI

81223 87470 NCCI

81223 87471 NCCI

81223 87472 NCCI

81223 87475 NCCI

81223 87476 NCCI

81223 87477 NCCI

81223 87480 NCCI

81223 87481 NCCI

81223 87482 NCCI

81223 87483 NCCI

81223 87485 NCCI

81223 87486 NCCI

81223 87487 NCCI

81223 87490 NCCI

81223 87491 NCCI

81223 87492 NCCI

81223 87493 NCCI

81223 87495 NCCI

81223 87496 NCCI

81223 87497 NCCI

81223 87498 NCCI

81223 87500 NCCI

81223 87501 NCCI

81223 87502 NCCI

81223 87503 NCCI

81223 87505 NCCI

81223 87506 NCCI

81223 87507 NCCI

81223 87510 NCCI

81223 87511 NCCI

81223 87512 NCCI

81223 87515 NCCI

81223 87516 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 35 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81223 87517 NCCI

81223 87520 NCCI

81223 87521 NCCI

81223 87522 NCCI

81223 87525 NCCI

81223 87526 NCCI

81223 87527 NCCI

81223 87528 NCCI

81223 87529 NCCI

81223 87530 NCCI

81223 87531 NCCI

81223 87532 NCCI

81223 87533 NCCI

81223 87534 NCCI

81223 87535 NCCI

81223 87536 NCCI

81223 87537 NCCI

81223 87538 NCCI

81223 87539 NCCI

81223 87540 NCCI

81223 87541 NCCI

81223 87542 NCCI

81223 87550 NCCI

81223 87551 NCCI

81223 87552 NCCI

81223 87555 NCCI

81223 87556 NCCI

81223 87557 NCCI

81223 87560 NCCI

81223 87561 NCCI

81223 87562 NCCI

81223 87580 NCCI

81223 87581 NCCI

81223 87582 NCCI

81223 87590 NCCI

81223 87591 NCCI

81223 87592 NCCI

81223 87623 NCCI

81223 87624 NCCI

81223 87625 NCCI

81223 87631 NCCI

81223 87632 NCCI

81223 87633 NCCI

81223 87640 NCCI

81223 87641 NCCI

81223 87650 NCCI

81223 87651 NCCI

Comprehensive ComponentCode Code Source

81223 87652 NCCI

81223 87653 NCCI

81223 87660 NCCI

81223 87661 NCCI

81223 87797 NCCI

81223 87798 NCCI

81223 87799 NCCI

81223 87800 NCCI

81223 87801 NCCI

81223 88271 NCCI

81223 88272 NCCI

81223 88273 NCCI

81223 88274 NCCI

81223 88275 NCCI

81223 88291 NCCI

81223 88364 NCCI

81223 88365 NCCI

81223 88366 NCCI

81223 88367 NCCI

81223 88368 NCCI

81223 88369 NCCI

81223 88373 NCCI

81223 88374 NCCI

81223 88377 NCCI

81223 G0476 NCCI

81224 80500 NCCI

81224 80502 NCCI

81224 84311 NCCI

81224 87140 NCCI

81224 87143 NCCI

81224 87147 NCCI

81224 87149 NCCI

81224 87150 NCCI

81224 87152 NCCI

81224 87153 NCCI

81224 87158 NCCI

81224 87470 NCCI

81224 87471 NCCI

81224 87472 NCCI

81224 87475 NCCI

81224 87476 NCCI

81224 87477 NCCI

81224 87480 NCCI

81224 87481 NCCI

81224 87482 NCCI

81224 87483 NCCI

81224 87485 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 36 of 255

Page 37: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81224 87486 NCCI

81224 87487 NCCI

81224 87490 NCCI

81224 87491 NCCI

81224 87492 NCCI

81224 87493 NCCI

81224 87495 NCCI

81224 87496 NCCI

81224 87497 NCCI

81224 87498 NCCI

81224 87500 NCCI

81224 87501 NCCI

81224 87502 NCCI

81224 87503 NCCI

81224 87505 NCCI

81224 87506 NCCI

81224 87507 NCCI

81224 87510 NCCI

81224 87511 NCCI

81224 87512 NCCI

81224 87515 NCCI

81224 87516 NCCI

81224 87517 NCCI

81224 87520 NCCI

81224 87521 NCCI

81224 87522 NCCI

81224 87525 NCCI

81224 87526 NCCI

81224 87527 NCCI

81224 87528 NCCI

81224 87529 NCCI

81224 87530 NCCI

81224 87531 NCCI

81224 87532 NCCI

81224 87533 NCCI

81224 87534 NCCI

81224 87535 NCCI

81224 87536 NCCI

81224 87537 NCCI

81224 87538 NCCI

81224 87539 NCCI

81224 87540 NCCI

81224 87541 NCCI

81224 87542 NCCI

81224 87550 NCCI

81224 87551 NCCI

81224 87552 NCCI

Comprehensive ComponentCode Code Source

81224 87555 NCCI

81224 87556 NCCI

81224 87557 NCCI

81224 87560 NCCI

81224 87561 NCCI

81224 87562 NCCI

81224 87580 NCCI

81224 87581 NCCI

81224 87582 NCCI

81224 87590 NCCI

81224 87591 NCCI

81224 87592 NCCI

81224 87623 NCCI

81224 87624 NCCI

81224 87625 NCCI

81224 87631 NCCI

81224 87632 NCCI

81224 87633 NCCI

81224 87640 NCCI

81224 87641 NCCI

81224 87650 NCCI

81224 87651 NCCI

81224 87652 NCCI

81224 87653 NCCI

81224 87660 NCCI

81224 87661 NCCI

81224 87797 NCCI

81224 87798 NCCI

81224 87799 NCCI

81224 87800 NCCI

81224 87801 NCCI

81224 88271 NCCI

81224 88272 NCCI

81224 88273 NCCI

81224 88274 NCCI

81224 88275 NCCI

81224 88291 NCCI

81224 88364 NCCI

81224 88365 NCCI

81224 88366 NCCI

81224 88367 NCCI

81224 88368 NCCI

81224 88369 NCCI

81224 88373 NCCI

81224 88374 NCCI

81224 88377 NCCI

81224 G0476 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 37 of 255

Page 38: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81225 80500 NCCI

81225 80502 NCCI

81225 84311 NCCI

81225 87140 NCCI

81225 87143 NCCI

81225 87147 NCCI

81225 87149 NCCI

81225 87150 NCCI

81225 87152 NCCI

81225 87153 NCCI

81225 87158 NCCI

81225 87470 NCCI

81225 87471 NCCI

81225 87472 NCCI

81225 87475 NCCI

81225 87476 NCCI

81225 87477 NCCI

81225 87480 NCCI

81225 87481 NCCI

81225 87482 NCCI

81225 87483 NCCI

81225 87485 NCCI

81225 87486 NCCI

81225 87487 NCCI

81225 87490 NCCI

81225 87491 NCCI

81225 87492 NCCI

81225 87493 NCCI

81225 87495 NCCI

81225 87496 NCCI

81225 87497 NCCI

81225 87498 NCCI

81225 87500 NCCI

81225 87501 NCCI

81225 87502 NCCI

81225 87503 NCCI

81225 87505 NCCI

81225 87506 NCCI

81225 87507 NCCI

81225 87510 NCCI

81225 87511 NCCI

81225 87512 NCCI

81225 87515 NCCI

81225 87516 NCCI

81225 87517 NCCI

81225 87520 NCCI

81225 87521 NCCI

Comprehensive ComponentCode Code Source

81225 87522 NCCI

81225 87525 NCCI

81225 87526 NCCI

81225 87527 NCCI

81225 87528 NCCI

81225 87529 NCCI

81225 87530 NCCI

81225 87531 NCCI

81225 87532 NCCI

81225 87533 NCCI

81225 87534 NCCI

81225 87535 NCCI

81225 87536 NCCI

81225 87537 NCCI

81225 87538 NCCI

81225 87539 NCCI

81225 87540 NCCI

81225 87541 NCCI

81225 87542 NCCI

81225 87550 NCCI

81225 87551 NCCI

81225 87552 NCCI

81225 87555 NCCI

81225 87556 NCCI

81225 87557 NCCI

81225 87560 NCCI

81225 87561 NCCI

81225 87562 NCCI

81225 87580 NCCI

81225 87581 NCCI

81225 87582 NCCI

81225 87590 NCCI

81225 87591 NCCI

81225 87592 NCCI

81225 87623 NCCI

81225 87624 NCCI

81225 87625 NCCI

81225 87631 NCCI

81225 87632 NCCI

81225 87633 NCCI

81225 87640 NCCI

81225 87641 NCCI

81225 87650 NCCI

81225 87651 NCCI

81225 87652 NCCI

81225 87653 NCCI

81225 87660 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 38 of 255

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Comprehensive ComponentCode Code Source

81225 87661 NCCI

81225 87797 NCCI

81225 87798 NCCI

81225 87799 NCCI

81225 87800 NCCI

81225 87801 NCCI

81225 88271 NCCI

81225 88272 NCCI

81225 88273 NCCI

81225 88274 NCCI

81225 88275 NCCI

81225 88291 NCCI

81225 88364 NCCI

81225 88365 NCCI

81225 88366 NCCI

81225 88367 NCCI

81225 88368 NCCI

81225 88369 NCCI

81225 88373 NCCI

81225 88374 NCCI

81225 88377 NCCI

81225 G0476 NCCI

81226 80500 NCCI

81226 80502 NCCI

81226 84311 NCCI

81226 87140 NCCI

81226 87143 NCCI

81226 87147 NCCI

81226 87149 NCCI

81226 87150 NCCI

81226 87152 NCCI

81226 87153 NCCI

81226 87158 NCCI

81226 87470 NCCI

81226 87471 NCCI

81226 87472 NCCI

81226 87475 NCCI

81226 87476 NCCI

81226 87477 NCCI

81226 87480 NCCI

81226 87481 NCCI

81226 87482 NCCI

81226 87483 NCCI

81226 87485 NCCI

81226 87486 NCCI

81226 87487 NCCI

81226 87490 NCCI

Comprehensive ComponentCode Code Source

81226 87491 NCCI

81226 87492 NCCI

81226 87493 NCCI

81226 87495 NCCI

81226 87496 NCCI

81226 87497 NCCI

81226 87498 NCCI

81226 87500 NCCI

81226 87501 NCCI

81226 87502 NCCI

81226 87503 NCCI

81226 87505 NCCI

81226 87506 NCCI

81226 87507 NCCI

81226 87510 NCCI

81226 87511 NCCI

81226 87512 NCCI

81226 87515 NCCI

81226 87516 NCCI

81226 87517 NCCI

81226 87520 NCCI

81226 87521 NCCI

81226 87522 NCCI

81226 87525 NCCI

81226 87526 NCCI

81226 87527 NCCI

81226 87528 NCCI

81226 87529 NCCI

81226 87530 NCCI

81226 87531 NCCI

81226 87532 NCCI

81226 87533 NCCI

81226 87534 NCCI

81226 87535 NCCI

81226 87536 NCCI

81226 87537 NCCI

81226 87538 NCCI

81226 87539 NCCI

81226 87540 NCCI

81226 87541 NCCI

81226 87542 NCCI

81226 87550 NCCI

81226 87551 NCCI

81226 87552 NCCI

81226 87555 NCCI

81226 87556 NCCI

81226 87557 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 39 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81226 87560 NCCI

81226 87561 NCCI

81226 87562 NCCI

81226 87580 NCCI

81226 87581 NCCI

81226 87582 NCCI

81226 87590 NCCI

81226 87591 NCCI

81226 87592 NCCI

81226 87623 NCCI

81226 87624 NCCI

81226 87625 NCCI

81226 87631 NCCI

81226 87632 NCCI

81226 87633 NCCI

81226 87640 NCCI

81226 87641 NCCI

81226 87650 NCCI

81226 87651 NCCI

81226 87652 NCCI

81226 87653 NCCI

81226 87660 NCCI

81226 87661 NCCI

81226 87797 NCCI

81226 87798 NCCI

81226 87799 NCCI

81226 87800 NCCI

81226 87801 NCCI

81226 88271 NCCI

81226 88272 NCCI

81226 88273 NCCI

81226 88274 NCCI

81226 88275 NCCI

81226 88291 NCCI

81226 88364 NCCI

81226 88365 NCCI

81226 88366 NCCI

81226 88367 NCCI

81226 88368 NCCI

81226 88369 NCCI

81226 88373 NCCI

81226 88374 NCCI

81226 88377 NCCI

81226 G0476 NCCI

81227 80500 NCCI

81227 80502 NCCI

81227 84311 NCCI

Comprehensive ComponentCode Code Source

81227 87140 NCCI

81227 87143 NCCI

81227 87147 NCCI

81227 87149 NCCI

81227 87150 NCCI

81227 87152 NCCI

81227 87153 NCCI

81227 87158 NCCI

81227 87470 NCCI

81227 87471 NCCI

81227 87472 NCCI

81227 87475 NCCI

81227 87476 NCCI

81227 87477 NCCI

81227 87480 NCCI

81227 87481 NCCI

81227 87482 NCCI

81227 87483 NCCI

81227 87485 NCCI

81227 87486 NCCI

81227 87487 NCCI

81227 87490 NCCI

81227 87491 NCCI

81227 87492 NCCI

81227 87493 NCCI

81227 87495 NCCI

81227 87496 NCCI

81227 87497 NCCI

81227 87498 NCCI

81227 87500 NCCI

81227 87501 NCCI

81227 87502 NCCI

81227 87503 NCCI

81227 87505 NCCI

81227 87506 NCCI

81227 87507 NCCI

81227 87510 NCCI

81227 87511 NCCI

81227 87512 NCCI

81227 87515 NCCI

81227 87516 NCCI

81227 87517 NCCI

81227 87520 NCCI

81227 87521 NCCI

81227 87522 NCCI

81227 87525 NCCI

81227 87526 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 40 of 255

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Comprehensive ComponentCode Code Source

81227 87527 NCCI

81227 87528 NCCI

81227 87529 NCCI

81227 87530 NCCI

81227 87531 NCCI

81227 87532 NCCI

81227 87533 NCCI

81227 87534 NCCI

81227 87535 NCCI

81227 87536 NCCI

81227 87537 NCCI

81227 87538 NCCI

81227 87539 NCCI

81227 87540 NCCI

81227 87541 NCCI

81227 87542 NCCI

81227 87550 NCCI

81227 87551 NCCI

81227 87552 NCCI

81227 87555 NCCI

81227 87556 NCCI

81227 87557 NCCI

81227 87560 NCCI

81227 87561 NCCI

81227 87562 NCCI

81227 87580 NCCI

81227 87581 NCCI

81227 87582 NCCI

81227 87590 NCCI

81227 87591 NCCI

81227 87592 NCCI

81227 87623 NCCI

81227 87624 NCCI

81227 87625 NCCI

81227 87631 NCCI

81227 87632 NCCI

81227 87633 NCCI

81227 87640 NCCI

81227 87641 NCCI

81227 87650 NCCI

81227 87651 NCCI

81227 87652 NCCI

81227 87653 NCCI

81227 87660 NCCI

81227 87661 NCCI

81227 87797 NCCI

81227 87798 NCCI

Comprehensive ComponentCode Code Source

81227 87799 NCCI

81227 87800 NCCI

81227 87801 NCCI

81227 88271 NCCI

81227 88272 NCCI

81227 88273 NCCI

81227 88274 NCCI

81227 88275 NCCI

81227 88291 NCCI

81227 88364 NCCI

81227 88365 NCCI

81227 88366 NCCI

81227 88367 NCCI

81227 88368 NCCI

81227 88369 NCCI

81227 88373 NCCI

81227 88374 NCCI

81227 88377 NCCI

81227 G0476 NCCI

81228 80500 NCCI

81228 80502 NCCI

81228 81161 NCCI

81228 81162 NCCI

81228 81170 NCCI

81228 81200 NCCI

81228 81201 NCCI

81228 81202 NCCI

81228 81203 NCCI

81228 81205 NCCI

81228 81206 NCCI

81228 81207 NCCI

81228 81208 NCCI

81228 81209 NCCI

81228 81210 NCCI

81228 81211 NCCI

81228 81212 NCCI

81228 81213 NCCI

81228 81214 NCCI

81228 81215 NCCI

81228 81216 NCCI

81228 81217 NCCI

81228 81218 NCCI

81228 81219 NCCI

81228 81220 NCCI

81228 81221 NCCI

81228 81222 NCCI

81228 81223 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 41 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81228 81224 NCCI

81228 81225 NCCI

81228 81226 NCCI

81228 81227 NCCI

81228 81229 NCCI

81228 81235 NCCI

81228 81240 NCCI

81228 81241 NCCI

81228 81242 NCCI

81228 81243 NCCI

81228 81244 NCCI

81228 81245 NCCI

81228 81246 NCCI

81228 81250 NCCI

81228 81251 NCCI

81228 81252 NCCI

81228 81253 NCCI

81228 81254 NCCI

81228 81255 NCCI

81228 81256 NCCI

81228 81257 NCCI

81228 81260 NCCI

81228 81261 NCCI

81228 81262 NCCI

81228 81263 NCCI

81228 81264 NCCI

81228 81265 NCCI

81228 81266 NCCI

81228 81267 NCCI

81228 81268 NCCI

81228 81270 NCCI

81228 81272 NCCI

81228 81273 NCCI

81228 81275 NCCI

81228 81276 NCCI

81228 81287 NCCI

81228 81288 NCCI

81228 81290 NCCI

81228 81291 NCCI

81228 81292 NCCI

81228 81293 NCCI

81228 81294 NCCI

81228 81295 NCCI

81228 81296 NCCI

81228 81297 NCCI

81228 81298 NCCI

81228 81299 NCCI

Comprehensive ComponentCode Code Source

81228 81300 NCCI

81228 81301 NCCI

81228 81302 NCCI

81228 81303 NCCI

81228 81304 NCCI

81228 81310 NCCI

81228 81311 NCCI

81228 81313 NCCI

81228 81314 NCCI

81228 81315 NCCI

81228 81316 NCCI

81228 81317 NCCI

81228 81318 NCCI

81228 81319 NCCI

81228 81321 NCCI

81228 81322 NCCI

81228 81323 NCCI

81228 81324 NCCI

81228 81325 NCCI

81228 81326 NCCI

81228 81327 NCCI

81228 81330 NCCI

81228 81331 NCCI

81228 81332 NCCI

81228 81340 NCCI

81228 81341 NCCI

81228 81342 NCCI

81228 81350 NCCI

81228 81355 NCCI

81228 81370 NCCI

81228 81371 NCCI

81228 81372 NCCI

81228 81373 NCCI

81228 81374 NCCI

81228 81375 NCCI

81228 81376 NCCI

81228 81377 NCCI

81228 81378 NCCI

81228 81379 NCCI

81228 81380 NCCI

81228 81381 NCCI

81228 81382 NCCI

81228 81383 NCCI

81228 81400 NCCI

81228 81401 NCCI

81228 81402 NCCI

81228 81403 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 42 of 255

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Comprehensive ComponentCode Code Source

81228 81404 NCCI

81228 81405 NCCI

81228 81406 NCCI

81228 81407 NCCI

81228 81408 NCCI

81228 81410 NCCI

81228 81411 NCCI

81228 81412 NCCI

81228 81415 NCCI

81228 81416 NCCI

81228 81417 NCCI

81228 81420 NCCI

81228 81425 NCCI

81228 81426 NCCI

81228 81427 NCCI

81228 81430 NCCI

81228 81431 NCCI

81228 81432 NCCI

81228 81433 NCCI

81228 81434 NCCI

81228 81435 NCCI

81228 81436 NCCI

81228 81437 NCCI

81228 81438 NCCI

81228 81440 NCCI

81228 81442 NCCI

81228 81445 NCCI

81228 81450 NCCI

81228 81455 NCCI

81228 81460 NCCI

81228 81465 NCCI

81228 81470 NCCI

81228 81471 NCCI

81228 84311 NCCI

81228 87140 NCCI

81228 87143 NCCI

81228 87147 NCCI

81228 87149 NCCI

81228 87150 NCCI

81228 87152 NCCI

81228 87153 NCCI

81228 87158 NCCI

81228 87470 NCCI

81228 87471 NCCI

81228 87472 NCCI

81228 87475 NCCI

81228 87476 NCCI

Comprehensive ComponentCode Code Source

81228 87477 NCCI

81228 87480 NCCI

81228 87481 NCCI

81228 87482 NCCI

81228 87483 NCCI

81228 87485 NCCI

81228 87486 NCCI

81228 87487 NCCI

81228 87490 NCCI

81228 87491 NCCI

81228 87492 NCCI

81228 87493 NCCI

81228 87495 NCCI

81228 87496 NCCI

81228 87497 NCCI

81228 87498 NCCI

81228 87500 NCCI

81228 87501 NCCI

81228 87502 NCCI

81228 87503 NCCI

81228 87505 NCCI

81228 87506 NCCI

81228 87507 NCCI

81228 87510 NCCI

81228 87511 NCCI

81228 87512 NCCI

81228 87515 NCCI

81228 87516 NCCI

81228 87517 NCCI

81228 87520 NCCI

81228 87521 NCCI

81228 87522 NCCI

81228 87525 NCCI

81228 87526 NCCI

81228 87527 NCCI

81228 87528 NCCI

81228 87529 NCCI

81228 87530 NCCI

81228 87531 NCCI

81228 87532 NCCI

81228 87533 NCCI

81228 87534 NCCI

81228 87535 NCCI

81228 87536 NCCI

81228 87537 NCCI

81228 87538 NCCI

81228 87539 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 43 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81228 87540 NCCI

81228 87541 NCCI

81228 87542 NCCI

81228 87550 NCCI

81228 87551 NCCI

81228 87552 NCCI

81228 87555 NCCI

81228 87556 NCCI

81228 87557 NCCI

81228 87560 NCCI

81228 87561 NCCI

81228 87562 NCCI

81228 87580 NCCI

81228 87581 NCCI

81228 87582 NCCI

81228 87590 NCCI

81228 87591 NCCI

81228 87592 NCCI

81228 87623 NCCI

81228 87624 NCCI

81228 87625 NCCI

81228 87631 NCCI

81228 87632 NCCI

81228 87633 NCCI

81228 87640 NCCI

81228 87641 NCCI

81228 87650 NCCI

81228 87651 NCCI

81228 87652 NCCI

81228 87653 NCCI

81228 87660 NCCI

81228 87661 NCCI

81228 87797 NCCI

81228 87798 NCCI

81228 87799 NCCI

81228 87800 NCCI

81228 87801 NCCI

81228 88271 NCCI

81228 88272 NCCI

81228 88273 NCCI

81228 88274 NCCI

81228 88275 NCCI

81228 88291 NCCI

81228 88364 NCCI

81228 88365 NCCI

81228 88366 NCCI

81228 88367 NCCI

Comprehensive ComponentCode Code Source

81228 88368 NCCI

81228 88369 NCCI

81228 88373 NCCI

81228 88374 NCCI

81228 88377 NCCI

81228 G0476 NCCI

81229 80500 NCCI

81229 80502 NCCI

81229 81161 NCCI

81229 81162 NCCI

81229 81170 NCCI

81229 81200 NCCI

81229 81201 NCCI

81229 81202 NCCI

81229 81203 NCCI

81229 81205 NCCI

81229 81206 NCCI

81229 81207 NCCI

81229 81208 NCCI

81229 81209 NCCI

81229 81210 NCCI

81229 81211 NCCI

81229 81212 NCCI

81229 81213 NCCI

81229 81214 NCCI

81229 81215 NCCI

81229 81216 NCCI

81229 81217 NCCI

81229 81218 NCCI

81229 81219 NCCI

81229 81220 NCCI

81229 81221 NCCI

81229 81222 NCCI

81229 81223 NCCI

81229 81224 NCCI

81229 81225 NCCI

81229 81226 NCCI

81229 81227 NCCI

81229 81235 NCCI

81229 81240 NCCI

81229 81241 NCCI

81229 81242 NCCI

81229 81243 NCCI

81229 81244 NCCI

81229 81245 NCCI

81229 81246 NCCI

81229 81250 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 44 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81229 81251 NCCI

81229 81252 NCCI

81229 81253 NCCI

81229 81254 NCCI

81229 81255 NCCI

81229 81256 NCCI

81229 81257 NCCI

81229 81260 NCCI

81229 81261 NCCI

81229 81262 NCCI

81229 81263 NCCI

81229 81264 NCCI

81229 81265 NCCI

81229 81266 NCCI

81229 81267 NCCI

81229 81268 NCCI

81229 81270 NCCI

81229 81272 NCCI

81229 81273 NCCI

81229 81275 NCCI

81229 81276 NCCI

81229 81287 NCCI

81229 81288 NCCI

81229 81290 NCCI

81229 81291 NCCI

81229 81292 NCCI

81229 81293 NCCI

81229 81294 NCCI

81229 81295 NCCI

81229 81296 NCCI

81229 81297 NCCI

81229 81298 NCCI

81229 81299 NCCI

81229 81300 NCCI

81229 81301 NCCI

81229 81302 NCCI

81229 81303 NCCI

81229 81304 NCCI

81229 81310 NCCI

81229 81311 NCCI

81229 81313 NCCI

81229 81314 NCCI

81229 81315 NCCI

81229 81316 NCCI

81229 81317 NCCI

81229 81318 NCCI

81229 81319 NCCI

Comprehensive ComponentCode Code Source

81229 81321 NCCI

81229 81322 NCCI

81229 81323 NCCI

81229 81324 NCCI

81229 81325 NCCI

81229 81326 NCCI

81229 81327 NCCI

81229 81330 NCCI

81229 81331 NCCI

81229 81332 NCCI

81229 81340 NCCI

81229 81341 NCCI

81229 81342 NCCI

81229 81350 NCCI

81229 81355 NCCI

81229 81370 NCCI

81229 81371 NCCI

81229 81372 NCCI

81229 81373 NCCI

81229 81374 NCCI

81229 81375 NCCI

81229 81376 NCCI

81229 81377 NCCI

81229 81378 NCCI

81229 81379 NCCI

81229 81380 NCCI

81229 81381 NCCI

81229 81382 NCCI

81229 81383 NCCI

81229 81400 NCCI

81229 81401 NCCI

81229 81402 NCCI

81229 81403 NCCI

81229 81404 NCCI

81229 81405 NCCI

81229 81406 NCCI

81229 81407 NCCI

81229 81408 NCCI

81229 81410 NCCI

81229 81411 NCCI

81229 81412 NCCI

81229 81415 NCCI

81229 81416 NCCI

81229 81417 NCCI

81229 81420 NCCI

81229 81425 NCCI

81229 81426 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 45 of 255

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Comprehensive ComponentCode Code Source

81229 81427 NCCI

81229 81430 NCCI

81229 81431 NCCI

81229 81432 NCCI

81229 81433 NCCI

81229 81434 NCCI

81229 81435 NCCI

81229 81436 NCCI

81229 81437 NCCI

81229 81438 NCCI

81229 81440 NCCI

81229 81442 NCCI

81229 81445 NCCI

81229 81450 NCCI

81229 81455 NCCI

81229 81460 NCCI

81229 81465 NCCI

81229 81470 NCCI

81229 81471 NCCI

81229 84311 NCCI

81229 87140 NCCI

81229 87143 NCCI

81229 87147 NCCI

81229 87149 NCCI

81229 87150 NCCI

81229 87152 NCCI

81229 87153 NCCI

81229 87158 NCCI

81229 87470 NCCI

81229 87471 NCCI

81229 87472 NCCI

81229 87475 NCCI

81229 87476 NCCI

81229 87477 NCCI

81229 87480 NCCI

81229 87481 NCCI

81229 87482 NCCI

81229 87483 NCCI

81229 87485 NCCI

81229 87486 NCCI

81229 87487 NCCI

81229 87490 NCCI

81229 87491 NCCI

81229 87492 NCCI

81229 87493 NCCI

81229 87495 NCCI

81229 87496 NCCI

Comprehensive ComponentCode Code Source

81229 87497 NCCI

81229 87498 NCCI

81229 87500 NCCI

81229 87501 NCCI

81229 87502 NCCI

81229 87503 NCCI

81229 87505 NCCI

81229 87506 NCCI

81229 87507 NCCI

81229 87510 NCCI

81229 87511 NCCI

81229 87512 NCCI

81229 87515 NCCI

81229 87516 NCCI

81229 87517 NCCI

81229 87520 NCCI

81229 87521 NCCI

81229 87522 NCCI

81229 87525 NCCI

81229 87526 NCCI

81229 87527 NCCI

81229 87528 NCCI

81229 87529 NCCI

81229 87530 NCCI

81229 87531 NCCI

81229 87532 NCCI

81229 87533 NCCI

81229 87534 NCCI

81229 87535 NCCI

81229 87536 NCCI

81229 87537 NCCI

81229 87538 NCCI

81229 87539 NCCI

81229 87540 NCCI

81229 87541 NCCI

81229 87542 NCCI

81229 87550 NCCI

81229 87551 NCCI

81229 87552 NCCI

81229 87555 NCCI

81229 87556 NCCI

81229 87557 NCCI

81229 87560 NCCI

81229 87561 NCCI

81229 87562 NCCI

81229 87580 NCCI

81229 87581 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 46 of 255

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Comprehensive ComponentCode Code Source

81229 87582 NCCI

81229 87590 NCCI

81229 87591 NCCI

81229 87592 NCCI

81229 87623 NCCI

81229 87624 NCCI

81229 87625 NCCI

81229 87631 NCCI

81229 87632 NCCI

81229 87633 NCCI

81229 87640 NCCI

81229 87641 NCCI

81229 87650 NCCI

81229 87651 NCCI

81229 87652 NCCI

81229 87653 NCCI

81229 87660 NCCI

81229 87661 NCCI

81229 87797 NCCI

81229 87798 NCCI

81229 87799 NCCI

81229 87800 NCCI

81229 87801 NCCI

81229 88271 NCCI

81229 88272 NCCI

81229 88273 NCCI

81229 88274 NCCI

81229 88275 NCCI

81229 88291 NCCI

81229 88364 NCCI

81229 88365 NCCI

81229 88366 NCCI

81229 88367 NCCI

81229 88368 NCCI

81229 88369 NCCI

81229 88373 NCCI

81229 88374 NCCI

81229 88377 NCCI

81229 G0476 NCCI

81235 80500 NCCI

81235 80502 NCCI

81235 84311 NCCI

81235 87140 NCCI

81235 87143 NCCI

81235 87147 NCCI

81235 87149 NCCI

81235 87150 NCCI

Comprehensive ComponentCode Code Source

81235 87152 NCCI

81235 87153 NCCI

81235 87158 NCCI

81235 87470 NCCI

81235 87471 NCCI

81235 87472 NCCI

81235 87475 NCCI

81235 87476 NCCI

81235 87477 NCCI

81235 87480 NCCI

81235 87481 NCCI

81235 87482 NCCI

81235 87483 NCCI

81235 87485 NCCI

81235 87486 NCCI

81235 87487 NCCI

81235 87490 NCCI

81235 87491 NCCI

81235 87492 NCCI

81235 87493 NCCI

81235 87495 NCCI

81235 87496 NCCI

81235 87497 NCCI

81235 87498 NCCI

81235 87500 NCCI

81235 87501 NCCI

81235 87502 NCCI

81235 87503 NCCI

81235 87505 NCCI

81235 87506 NCCI

81235 87507 NCCI

81235 87510 NCCI

81235 87511 NCCI

81235 87512 NCCI

81235 87515 NCCI

81235 87516 NCCI

81235 87517 NCCI

81235 87520 NCCI

81235 87521 NCCI

81235 87522 NCCI

81235 87525 NCCI

81235 87526 NCCI

81235 87527 NCCI

81235 87528 NCCI

81235 87529 NCCI

81235 87530 NCCI

81235 87531 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 47 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81235 87532 NCCI

81235 87533 NCCI

81235 87534 NCCI

81235 87535 NCCI

81235 87536 NCCI

81235 87537 NCCI

81235 87538 NCCI

81235 87539 NCCI

81235 87540 NCCI

81235 87541 NCCI

81235 87542 NCCI

81235 87550 NCCI

81235 87551 NCCI

81235 87552 NCCI

81235 87555 NCCI

81235 87556 NCCI

81235 87557 NCCI

81235 87560 NCCI

81235 87561 NCCI

81235 87562 NCCI

81235 87580 NCCI

81235 87581 NCCI

81235 87582 NCCI

81235 87590 NCCI

81235 87591 NCCI

81235 87592 NCCI

81235 87623 NCCI

81235 87624 NCCI

81235 87625 NCCI

81235 87631 NCCI

81235 87632 NCCI

81235 87633 NCCI

81235 87640 NCCI

81235 87641 NCCI

81235 87650 NCCI

81235 87651 NCCI

81235 87652 NCCI

81235 87653 NCCI

81235 87660 NCCI

81235 87661 NCCI

81235 87797 NCCI

81235 87798 NCCI

81235 87799 NCCI

81235 87800 NCCI

81235 87801 NCCI

81235 88271 NCCI

81235 88272 NCCI

Comprehensive ComponentCode Code Source

81235 88273 NCCI

81235 88274 NCCI

81235 88275 NCCI

81235 88291 NCCI

81235 88364 NCCI

81235 88365 NCCI

81235 88366 NCCI

81235 88367 NCCI

81235 88368 NCCI

81235 88369 NCCI

81235 88373 NCCI

81235 88374 NCCI

81235 88377 NCCI

81235 G0476 NCCI

81240 80500 NCCI

81240 80502 NCCI

81240 84311 NCCI

81240 87140 NCCI

81240 87143 NCCI

81240 87147 NCCI

81240 87149 NCCI

81240 87150 NCCI

81240 87152 NCCI

81240 87153 NCCI

81240 87158 NCCI

81240 87470 NCCI

81240 87471 NCCI

81240 87472 NCCI

81240 87475 NCCI

81240 87476 NCCI

81240 87477 NCCI

81240 87480 NCCI

81240 87481 NCCI

81240 87482 NCCI

81240 87483 NCCI

81240 87485 NCCI

81240 87486 NCCI

81240 87487 NCCI

81240 87490 NCCI

81240 87491 NCCI

81240 87492 NCCI

81240 87493 NCCI

81240 87495 NCCI

81240 87496 NCCI

81240 87497 NCCI

81240 87498 NCCI

81240 87500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 48 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81240 87501 NCCI

81240 87502 NCCI

81240 87503 NCCI

81240 87505 NCCI

81240 87506 NCCI

81240 87507 NCCI

81240 87510 NCCI

81240 87511 NCCI

81240 87512 NCCI

81240 87515 NCCI

81240 87516 NCCI

81240 87517 NCCI

81240 87520 NCCI

81240 87521 NCCI

81240 87522 NCCI

81240 87525 NCCI

81240 87526 NCCI

81240 87527 NCCI

81240 87528 NCCI

81240 87529 NCCI

81240 87530 NCCI

81240 87531 NCCI

81240 87532 NCCI

81240 87533 NCCI

81240 87534 NCCI

81240 87535 NCCI

81240 87536 NCCI

81240 87537 NCCI

81240 87538 NCCI

81240 87539 NCCI

81240 87540 NCCI

81240 87541 NCCI

81240 87542 NCCI

81240 87550 NCCI

81240 87551 NCCI

81240 87552 NCCI

81240 87555 NCCI

81240 87556 NCCI

81240 87557 NCCI

81240 87560 NCCI

81240 87561 NCCI

81240 87562 NCCI

81240 87580 NCCI

81240 87581 NCCI

81240 87582 NCCI

81240 87590 NCCI

81240 87591 NCCI

Comprehensive ComponentCode Code Source

81240 87592 NCCI

81240 87623 NCCI

81240 87624 NCCI

81240 87625 NCCI

81240 87631 NCCI

81240 87632 NCCI

81240 87633 NCCI

81240 87640 NCCI

81240 87641 NCCI

81240 87650 NCCI

81240 87651 NCCI

81240 87652 NCCI

81240 87653 NCCI

81240 87660 NCCI

81240 87661 NCCI

81240 87797 NCCI

81240 87798 NCCI

81240 87799 NCCI

81240 87800 NCCI

81240 87801 NCCI

81240 88271 NCCI

81240 88272 NCCI

81240 88273 NCCI

81240 88274 NCCI

81240 88275 NCCI

81240 88291 NCCI

81240 88364 NCCI

81240 88365 NCCI

81240 88366 NCCI

81240 88367 NCCI

81240 88368 NCCI

81240 88369 NCCI

81240 88373 NCCI

81240 88374 NCCI

81240 88377 NCCI

81240 G0476 NCCI

81241 80500 NCCI

81241 80502 NCCI

81241 84311 NCCI

81241 87140 NCCI

81241 87143 NCCI

81241 87147 NCCI

81241 87149 NCCI

81241 87150 NCCI

81241 87152 NCCI

81241 87153 NCCI

81241 87158 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 49 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81241 87470 NCCI

81241 87471 NCCI

81241 87472 NCCI

81241 87475 NCCI

81241 87476 NCCI

81241 87477 NCCI

81241 87480 NCCI

81241 87481 NCCI

81241 87482 NCCI

81241 87483 NCCI

81241 87485 NCCI

81241 87486 NCCI

81241 87487 NCCI

81241 87490 NCCI

81241 87491 NCCI

81241 87492 NCCI

81241 87493 NCCI

81241 87495 NCCI

81241 87496 NCCI

81241 87497 NCCI

81241 87498 NCCI

81241 87500 NCCI

81241 87501 NCCI

81241 87502 NCCI

81241 87503 NCCI

81241 87505 NCCI

81241 87506 NCCI

81241 87507 NCCI

81241 87510 NCCI

81241 87511 NCCI

81241 87512 NCCI

81241 87515 NCCI

81241 87516 NCCI

81241 87517 NCCI

81241 87520 NCCI

81241 87521 NCCI

81241 87522 NCCI

81241 87525 NCCI

81241 87526 NCCI

81241 87527 NCCI

81241 87528 NCCI

81241 87529 NCCI

81241 87530 NCCI

81241 87531 NCCI

81241 87532 NCCI

81241 87533 NCCI

81241 87534 NCCI

Comprehensive ComponentCode Code Source

81241 87535 NCCI

81241 87536 NCCI

81241 87537 NCCI

81241 87538 NCCI

81241 87539 NCCI

81241 87540 NCCI

81241 87541 NCCI

81241 87542 NCCI

81241 87550 NCCI

81241 87551 NCCI

81241 87552 NCCI

81241 87555 NCCI

81241 87556 NCCI

81241 87557 NCCI

81241 87560 NCCI

81241 87561 NCCI

81241 87562 NCCI

81241 87580 NCCI

81241 87581 NCCI

81241 87582 NCCI

81241 87590 NCCI

81241 87591 NCCI

81241 87592 NCCI

81241 87623 NCCI

81241 87624 NCCI

81241 87625 NCCI

81241 87631 NCCI

81241 87632 NCCI

81241 87633 NCCI

81241 87640 NCCI

81241 87641 NCCI

81241 87650 NCCI

81241 87651 NCCI

81241 87652 NCCI

81241 87653 NCCI

81241 87660 NCCI

81241 87661 NCCI

81241 87797 NCCI

81241 87798 NCCI

81241 87799 NCCI

81241 87800 NCCI

81241 87801 NCCI

81241 88271 NCCI

81241 88272 NCCI

81241 88273 NCCI

81241 88274 NCCI

81241 88275 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 50 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81241 88291 NCCI

81241 88364 NCCI

81241 88365 NCCI

81241 88366 NCCI

81241 88367 NCCI

81241 88368 NCCI

81241 88369 NCCI

81241 88373 NCCI

81241 88374 NCCI

81241 88377 NCCI

81241 G0476 NCCI

81242 80500 NCCI

81242 80502 NCCI

81242 84311 NCCI

81242 87140 NCCI

81242 87143 NCCI

81242 87147 NCCI

81242 87149 NCCI

81242 87150 NCCI

81242 87152 NCCI

81242 87153 NCCI

81242 87158 NCCI

81242 87470 NCCI

81242 87471 NCCI

81242 87472 NCCI

81242 87475 NCCI

81242 87476 NCCI

81242 87477 NCCI

81242 87480 NCCI

81242 87481 NCCI

81242 87482 NCCI

81242 87483 NCCI

81242 87485 NCCI

81242 87486 NCCI

81242 87487 NCCI

81242 87490 NCCI

81242 87491 NCCI

81242 87492 NCCI

81242 87493 NCCI

81242 87495 NCCI

81242 87496 NCCI

81242 87497 NCCI

81242 87498 NCCI

81242 87500 NCCI

81242 87501 NCCI

81242 87502 NCCI

81242 87503 NCCI

Comprehensive ComponentCode Code Source

81242 87505 NCCI

81242 87506 NCCI

81242 87507 NCCI

81242 87510 NCCI

81242 87511 NCCI

81242 87512 NCCI

81242 87515 NCCI

81242 87516 NCCI

81242 87517 NCCI

81242 87520 NCCI

81242 87521 NCCI

81242 87522 NCCI

81242 87525 NCCI

81242 87526 NCCI

81242 87527 NCCI

81242 87528 NCCI

81242 87529 NCCI

81242 87530 NCCI

81242 87531 NCCI

81242 87532 NCCI

81242 87533 NCCI

81242 87534 NCCI

81242 87535 NCCI

81242 87536 NCCI

81242 87537 NCCI

81242 87538 NCCI

81242 87539 NCCI

81242 87540 NCCI

81242 87541 NCCI

81242 87542 NCCI

81242 87550 NCCI

81242 87551 NCCI

81242 87552 NCCI

81242 87555 NCCI

81242 87556 NCCI

81242 87557 NCCI

81242 87560 NCCI

81242 87561 NCCI

81242 87562 NCCI

81242 87580 NCCI

81242 87581 NCCI

81242 87582 NCCI

81242 87590 NCCI

81242 87591 NCCI

81242 87592 NCCI

81242 87623 NCCI

81242 87624 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 51 of 255

Page 52: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81242 87625 NCCI

81242 87631 NCCI

81242 87632 NCCI

81242 87633 NCCI

81242 87640 NCCI

81242 87641 NCCI

81242 87650 NCCI

81242 87651 NCCI

81242 87652 NCCI

81242 87653 NCCI

81242 87660 NCCI

81242 87661 NCCI

81242 87797 NCCI

81242 87798 NCCI

81242 87799 NCCI

81242 87800 NCCI

81242 87801 NCCI

81242 88271 NCCI

81242 88272 NCCI

81242 88273 NCCI

81242 88274 NCCI

81242 88275 NCCI

81242 88291 NCCI

81242 88364 NCCI

81242 88365 NCCI

81242 88366 NCCI

81242 88367 NCCI

81242 88368 NCCI

81242 88369 NCCI

81242 88373 NCCI

81242 88374 NCCI

81242 88377 NCCI

81242 G0476 NCCI

81243 80500 NCCI

81243 80502 NCCI

81243 84311 NCCI

81243 87140 NCCI

81243 87143 NCCI

81243 87147 NCCI

81243 87149 NCCI

81243 87150 NCCI

81243 87152 NCCI

81243 87153 NCCI

81243 87158 NCCI

81243 87470 NCCI

81243 87471 NCCI

81243 87472 NCCI

Comprehensive ComponentCode Code Source

81243 87475 NCCI

81243 87476 NCCI

81243 87477 NCCI

81243 87480 NCCI

81243 87481 NCCI

81243 87482 NCCI

81243 87483 NCCI

81243 87485 NCCI

81243 87486 NCCI

81243 87487 NCCI

81243 87490 NCCI

81243 87491 NCCI

81243 87492 NCCI

81243 87493 NCCI

81243 87495 NCCI

81243 87496 NCCI

81243 87497 NCCI

81243 87498 NCCI

81243 87500 NCCI

81243 87501 NCCI

81243 87502 NCCI

81243 87503 NCCI

81243 87505 NCCI

81243 87506 NCCI

81243 87507 NCCI

81243 87510 NCCI

81243 87511 NCCI

81243 87512 NCCI

81243 87515 NCCI

81243 87516 NCCI

81243 87517 NCCI

81243 87520 NCCI

81243 87521 NCCI

81243 87522 NCCI

81243 87525 NCCI

81243 87526 NCCI

81243 87527 NCCI

81243 87528 NCCI

81243 87529 NCCI

81243 87530 NCCI

81243 87531 NCCI

81243 87532 NCCI

81243 87533 NCCI

81243 87534 NCCI

81243 87535 NCCI

81243 87536 NCCI

81243 87537 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 52 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81243 87538 NCCI

81243 87539 NCCI

81243 87540 NCCI

81243 87541 NCCI

81243 87542 NCCI

81243 87550 NCCI

81243 87551 NCCI

81243 87552 NCCI

81243 87555 NCCI

81243 87556 NCCI

81243 87557 NCCI

81243 87560 NCCI

81243 87561 NCCI

81243 87562 NCCI

81243 87580 NCCI

81243 87581 NCCI

81243 87582 NCCI

81243 87590 NCCI

81243 87591 NCCI

81243 87592 NCCI

81243 87623 NCCI

81243 87624 NCCI

81243 87625 NCCI

81243 87631 NCCI

81243 87632 NCCI

81243 87633 NCCI

81243 87640 NCCI

81243 87641 NCCI

81243 87650 NCCI

81243 87651 NCCI

81243 87652 NCCI

81243 87653 NCCI

81243 87660 NCCI

81243 87661 NCCI

81243 87797 NCCI

81243 87798 NCCI

81243 87799 NCCI

81243 87800 NCCI

81243 87801 NCCI

81243 88271 NCCI

81243 88272 NCCI

81243 88273 NCCI

81243 88274 NCCI

81243 88275 NCCI

81243 88291 NCCI

81243 88364 NCCI

81243 88365 NCCI

Comprehensive ComponentCode Code Source

81243 88366 NCCI

81243 88367 NCCI

81243 88368 NCCI

81243 88369 NCCI

81243 88373 NCCI

81243 88374 NCCI

81243 88377 NCCI

81243 G0476 NCCI

81244 80500 NCCI

81244 80502 NCCI

81244 81243 NCCI

81244 84311 NCCI

81244 87140 NCCI

81244 87143 NCCI

81244 87147 NCCI

81244 87149 NCCI

81244 87150 NCCI

81244 87152 NCCI

81244 87153 NCCI

81244 87158 NCCI

81244 87470 NCCI

81244 87471 NCCI

81244 87472 NCCI

81244 87475 NCCI

81244 87476 NCCI

81244 87477 NCCI

81244 87480 NCCI

81244 87481 NCCI

81244 87482 NCCI

81244 87483 NCCI

81244 87485 NCCI

81244 87486 NCCI

81244 87487 NCCI

81244 87490 NCCI

81244 87491 NCCI

81244 87492 NCCI

81244 87493 NCCI

81244 87495 NCCI

81244 87496 NCCI

81244 87497 NCCI

81244 87498 NCCI

81244 87500 NCCI

81244 87501 NCCI

81244 87502 NCCI

81244 87503 NCCI

81244 87505 NCCI

81244 87506 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 53 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81244 87507 NCCI

81244 87510 NCCI

81244 87511 NCCI

81244 87512 NCCI

81244 87515 NCCI

81244 87516 NCCI

81244 87517 NCCI

81244 87520 NCCI

81244 87521 NCCI

81244 87522 NCCI

81244 87525 NCCI

81244 87526 NCCI

81244 87527 NCCI

81244 87528 NCCI

81244 87529 NCCI

81244 87530 NCCI

81244 87531 NCCI

81244 87532 NCCI

81244 87533 NCCI

81244 87534 NCCI

81244 87535 NCCI

81244 87536 NCCI

81244 87537 NCCI

81244 87538 NCCI

81244 87539 NCCI

81244 87540 NCCI

81244 87541 NCCI

81244 87542 NCCI

81244 87550 NCCI

81244 87551 NCCI

81244 87552 NCCI

81244 87555 NCCI

81244 87556 NCCI

81244 87557 NCCI

81244 87560 NCCI

81244 87561 NCCI

81244 87562 NCCI

81244 87580 NCCI

81244 87581 NCCI

81244 87582 NCCI

81244 87590 NCCI

81244 87591 NCCI

81244 87592 NCCI

81244 87623 NCCI

81244 87624 NCCI

81244 87625 NCCI

81244 87631 NCCI

Comprehensive ComponentCode Code Source

81244 87632 NCCI

81244 87633 NCCI

81244 87640 NCCI

81244 87641 NCCI

81244 87650 NCCI

81244 87651 NCCI

81244 87652 NCCI

81244 87653 NCCI

81244 87660 NCCI

81244 87661 NCCI

81244 87797 NCCI

81244 87798 NCCI

81244 87799 NCCI

81244 87800 NCCI

81244 87801 NCCI

81244 88271 NCCI

81244 88272 NCCI

81244 88273 NCCI

81244 88274 NCCI

81244 88275 NCCI

81244 88291 NCCI

81244 88364 NCCI

81244 88365 NCCI

81244 88366 NCCI

81244 88367 NCCI

81244 88368 NCCI

81244 88369 NCCI

81244 88373 NCCI

81244 88374 NCCI

81244 88377 NCCI

81244 G0476 NCCI

81245 80500 NCCI

81245 80502 NCCI

81245 84311 NCCI

81245 87140 NCCI

81245 87143 NCCI

81245 87147 NCCI

81245 87149 NCCI

81245 87150 NCCI

81245 87152 NCCI

81245 87153 NCCI

81245 87158 NCCI

81245 87470 NCCI

81245 87471 NCCI

81245 87472 NCCI

81245 87475 NCCI

81245 87476 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 54 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81245 87477 NCCI

81245 87480 NCCI

81245 87481 NCCI

81245 87482 NCCI

81245 87483 NCCI

81245 87485 NCCI

81245 87486 NCCI

81245 87487 NCCI

81245 87490 NCCI

81245 87491 NCCI

81245 87492 NCCI

81245 87493 NCCI

81245 87495 NCCI

81245 87496 NCCI

81245 87497 NCCI

81245 87498 NCCI

81245 87500 NCCI

81245 87501 NCCI

81245 87502 NCCI

81245 87503 NCCI

81245 87505 NCCI

81245 87506 NCCI

81245 87507 NCCI

81245 87510 NCCI

81245 87511 NCCI

81245 87512 NCCI

81245 87515 NCCI

81245 87516 NCCI

81245 87517 NCCI

81245 87520 NCCI

81245 87521 NCCI

81245 87522 NCCI

81245 87525 NCCI

81245 87526 NCCI

81245 87527 NCCI

81245 87528 NCCI

81245 87529 NCCI

81245 87530 NCCI

81245 87531 NCCI

81245 87532 NCCI

81245 87533 NCCI

81245 87534 NCCI

81245 87535 NCCI

81245 87536 NCCI

81245 87537 NCCI

81245 87538 NCCI

81245 87539 NCCI

Comprehensive ComponentCode Code Source

81245 87540 NCCI

81245 87541 NCCI

81245 87542 NCCI

81245 87550 NCCI

81245 87551 NCCI

81245 87552 NCCI

81245 87555 NCCI

81245 87556 NCCI

81245 87557 NCCI

81245 87560 NCCI

81245 87561 NCCI

81245 87562 NCCI

81245 87580 NCCI

81245 87581 NCCI

81245 87582 NCCI

81245 87590 NCCI

81245 87591 NCCI

81245 87592 NCCI

81245 87623 NCCI

81245 87624 NCCI

81245 87625 NCCI

81245 87631 NCCI

81245 87632 NCCI

81245 87633 NCCI

81245 87640 NCCI

81245 87641 NCCI

81245 87650 NCCI

81245 87651 NCCI

81245 87652 NCCI

81245 87653 NCCI

81245 87660 NCCI

81245 87661 NCCI

81245 87797 NCCI

81245 87798 NCCI

81245 87799 NCCI

81245 87800 NCCI

81245 87801 NCCI

81245 88271 NCCI

81245 88272 NCCI

81245 88273 NCCI

81245 88274 NCCI

81245 88275 NCCI

81245 88291 NCCI

81245 88364 NCCI

81245 88365 NCCI

81245 88366 NCCI

81245 88367 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 55 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81245 88368 NCCI

81245 88369 NCCI

81245 88373 NCCI

81245 88374 NCCI

81245 88377 NCCI

81245 G0476 NCCI

81246 80500 NCCI

81246 80502 NCCI

81246 84311 NCCI

81246 87140 NCCI

81246 87143 NCCI

81246 87147 NCCI

81246 87149 NCCI

81246 87150 NCCI

81246 87152 NCCI

81246 87153 NCCI

81246 87158 NCCI

81246 87470 NCCI

81246 87471 NCCI

81246 87472 NCCI

81246 87475 NCCI

81246 87476 NCCI

81246 87477 NCCI

81246 87480 NCCI

81246 87481 NCCI

81246 87482 NCCI

81246 87483 NCCI

81246 87485 NCCI

81246 87486 NCCI

81246 87487 NCCI

81246 87490 NCCI

81246 87491 NCCI

81246 87492 NCCI

81246 87493 NCCI

81246 87495 NCCI

81246 87496 NCCI

81246 87497 NCCI

81246 87498 NCCI

81246 87500 NCCI

81246 87501 NCCI

81246 87502 NCCI

81246 87503 NCCI

81246 87505 NCCI

81246 87506 NCCI

81246 87507 NCCI

81246 87510 NCCI

81246 87511 NCCI

Comprehensive ComponentCode Code Source

81246 87512 NCCI

81246 87515 NCCI

81246 87516 NCCI

81246 87517 NCCI

81246 87520 NCCI

81246 87521 NCCI

81246 87522 NCCI

81246 87525 NCCI

81246 87526 NCCI

81246 87527 NCCI

81246 87528 NCCI

81246 87529 NCCI

81246 87530 NCCI

81246 87531 NCCI

81246 87532 NCCI

81246 87533 NCCI

81246 87534 NCCI

81246 87535 NCCI

81246 87536 NCCI

81246 87537 NCCI

81246 87538 NCCI

81246 87539 NCCI

81246 87540 NCCI

81246 87541 NCCI

81246 87542 NCCI

81246 87550 NCCI

81246 87551 NCCI

81246 87552 NCCI

81246 87555 NCCI

81246 87556 NCCI

81246 87557 NCCI

81246 87560 NCCI

81246 87561 NCCI

81246 87562 NCCI

81246 87580 NCCI

81246 87581 NCCI

81246 87582 NCCI

81246 87590 NCCI

81246 87591 NCCI

81246 87592 NCCI

81246 87623 NCCI

81246 87624 NCCI

81246 87625 NCCI

81246 87631 NCCI

81246 87632 NCCI

81246 87633 NCCI

81246 87640 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 56 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81246 87641 NCCI

81246 87650 NCCI

81246 87651 NCCI

81246 87652 NCCI

81246 87653 NCCI

81246 87660 NCCI

81246 87661 NCCI

81246 87797 NCCI

81246 87798 NCCI

81246 87799 NCCI

81246 87800 NCCI

81246 87801 NCCI

81246 88271 NCCI

81246 88272 NCCI

81246 88273 NCCI

81246 88274 NCCI

81246 88275 NCCI

81246 88291 NCCI

81246 88364 NCCI

81246 88365 NCCI

81246 88366 NCCI

81246 88367 NCCI

81246 88368 NCCI

81246 88369 NCCI

81246 88373 NCCI

81246 88374 NCCI

81246 88377 NCCI

81246 G0476 NCCI

81250 80500 NCCI

81250 80502 NCCI

81250 84311 NCCI

81250 87140 NCCI

81250 87143 NCCI

81250 87147 NCCI

81250 87149 NCCI

81250 87150 NCCI

81250 87152 NCCI

81250 87153 NCCI

81250 87158 NCCI

81250 87470 NCCI

81250 87471 NCCI

81250 87472 NCCI

81250 87475 NCCI

81250 87476 NCCI

81250 87477 NCCI

81250 87480 NCCI

81250 87481 NCCI

Comprehensive ComponentCode Code Source

81250 87482 NCCI

81250 87483 NCCI

81250 87485 NCCI

81250 87486 NCCI

81250 87487 NCCI

81250 87490 NCCI

81250 87491 NCCI

81250 87492 NCCI

81250 87493 NCCI

81250 87495 NCCI

81250 87496 NCCI

81250 87497 NCCI

81250 87498 NCCI

81250 87500 NCCI

81250 87501 NCCI

81250 87502 NCCI

81250 87503 NCCI

81250 87505 NCCI

81250 87506 NCCI

81250 87507 NCCI

81250 87510 NCCI

81250 87511 NCCI

81250 87512 NCCI

81250 87515 NCCI

81250 87516 NCCI

81250 87517 NCCI

81250 87520 NCCI

81250 87521 NCCI

81250 87522 NCCI

81250 87525 NCCI

81250 87526 NCCI

81250 87527 NCCI

81250 87528 NCCI

81250 87529 NCCI

81250 87530 NCCI

81250 87531 NCCI

81250 87532 NCCI

81250 87533 NCCI

81250 87534 NCCI

81250 87535 NCCI

81250 87536 NCCI

81250 87537 NCCI

81250 87538 NCCI

81250 87539 NCCI

81250 87540 NCCI

81250 87541 NCCI

81250 87542 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 57 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81250 87550 NCCI

81250 87551 NCCI

81250 87552 NCCI

81250 87555 NCCI

81250 87556 NCCI

81250 87557 NCCI

81250 87560 NCCI

81250 87561 NCCI

81250 87562 NCCI

81250 87580 NCCI

81250 87581 NCCI

81250 87582 NCCI

81250 87590 NCCI

81250 87591 NCCI

81250 87592 NCCI

81250 87623 NCCI

81250 87624 NCCI

81250 87625 NCCI

81250 87631 NCCI

81250 87632 NCCI

81250 87633 NCCI

81250 87640 NCCI

81250 87641 NCCI

81250 87650 NCCI

81250 87651 NCCI

81250 87652 NCCI

81250 87653 NCCI

81250 87660 NCCI

81250 87661 NCCI

81250 87797 NCCI

81250 87798 NCCI

81250 87799 NCCI

81250 87800 NCCI

81250 87801 NCCI

81250 88271 NCCI

81250 88272 NCCI

81250 88273 NCCI

81250 88274 NCCI

81250 88275 NCCI

81250 88291 NCCI

81250 88364 NCCI

81250 88365 NCCI

81250 88366 NCCI

81250 88367 NCCI

81250 88368 NCCI

81250 88369 NCCI

81250 88373 NCCI

Comprehensive ComponentCode Code Source

81250 88374 NCCI

81250 88377 NCCI

81250 G0476 NCCI

81251 80500 NCCI

81251 80502 NCCI

81251 84311 NCCI

81251 87140 NCCI

81251 87143 NCCI

81251 87147 NCCI

81251 87149 NCCI

81251 87150 NCCI

81251 87152 NCCI

81251 87153 NCCI

81251 87158 NCCI

81251 87470 NCCI

81251 87471 NCCI

81251 87472 NCCI

81251 87475 NCCI

81251 87476 NCCI

81251 87477 NCCI

81251 87480 NCCI

81251 87481 NCCI

81251 87482 NCCI

81251 87483 NCCI

81251 87485 NCCI

81251 87486 NCCI

81251 87487 NCCI

81251 87490 NCCI

81251 87491 NCCI

81251 87492 NCCI

81251 87493 NCCI

81251 87495 NCCI

81251 87496 NCCI

81251 87497 NCCI

81251 87498 NCCI

81251 87500 NCCI

81251 87501 NCCI

81251 87502 NCCI

81251 87503 NCCI

81251 87505 NCCI

81251 87506 NCCI

81251 87507 NCCI

81251 87510 NCCI

81251 87511 NCCI

81251 87512 NCCI

81251 87515 NCCI

81251 87516 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 58 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81251 87517 NCCI

81251 87520 NCCI

81251 87521 NCCI

81251 87522 NCCI

81251 87525 NCCI

81251 87526 NCCI

81251 87527 NCCI

81251 87528 NCCI

81251 87529 NCCI

81251 87530 NCCI

81251 87531 NCCI

81251 87532 NCCI

81251 87533 NCCI

81251 87534 NCCI

81251 87535 NCCI

81251 87536 NCCI

81251 87537 NCCI

81251 87538 NCCI

81251 87539 NCCI

81251 87540 NCCI

81251 87541 NCCI

81251 87542 NCCI

81251 87550 NCCI

81251 87551 NCCI

81251 87552 NCCI

81251 87555 NCCI

81251 87556 NCCI

81251 87557 NCCI

81251 87560 NCCI

81251 87561 NCCI

81251 87562 NCCI

81251 87580 NCCI

81251 87581 NCCI

81251 87582 NCCI

81251 87590 NCCI

81251 87591 NCCI

81251 87592 NCCI

81251 87623 NCCI

81251 87624 NCCI

81251 87625 NCCI

81251 87631 NCCI

81251 87632 NCCI

81251 87633 NCCI

81251 87640 NCCI

81251 87641 NCCI

81251 87650 NCCI

81251 87651 NCCI

Comprehensive ComponentCode Code Source

81251 87652 NCCI

81251 87653 NCCI

81251 87660 NCCI

81251 87661 NCCI

81251 87797 NCCI

81251 87798 NCCI

81251 87799 NCCI

81251 87800 NCCI

81251 87801 NCCI

81251 88271 NCCI

81251 88272 NCCI

81251 88273 NCCI

81251 88274 NCCI

81251 88275 NCCI

81251 88291 NCCI

81251 88364 NCCI

81251 88365 NCCI

81251 88366 NCCI

81251 88367 NCCI

81251 88368 NCCI

81251 88369 NCCI

81251 88373 NCCI

81251 88374 NCCI

81251 88377 NCCI

81251 G0476 NCCI

81252 80500 NCCI

81252 80502 NCCI

81252 81253 NCCI

81252 84311 NCCI

81252 87140 NCCI

81252 87143 NCCI

81252 87147 NCCI

81252 87149 NCCI

81252 87150 NCCI

81252 87152 NCCI

81252 87153 NCCI

81252 87158 NCCI

81252 87470 NCCI

81252 87471 NCCI

81252 87472 NCCI

81252 87475 NCCI

81252 87476 NCCI

81252 87477 NCCI

81252 87480 NCCI

81252 87481 NCCI

81252 87482 NCCI

81252 87483 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 59 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81252 87485 NCCI

81252 87486 NCCI

81252 87487 NCCI

81252 87490 NCCI

81252 87491 NCCI

81252 87492 NCCI

81252 87493 NCCI

81252 87495 NCCI

81252 87496 NCCI

81252 87497 NCCI

81252 87498 NCCI

81252 87500 NCCI

81252 87501 NCCI

81252 87502 NCCI

81252 87503 NCCI

81252 87505 NCCI

81252 87506 NCCI

81252 87507 NCCI

81252 87510 NCCI

81252 87511 NCCI

81252 87512 NCCI

81252 87515 NCCI

81252 87516 NCCI

81252 87517 NCCI

81252 87520 NCCI

81252 87521 NCCI

81252 87522 NCCI

81252 87525 NCCI

81252 87526 NCCI

81252 87527 NCCI

81252 87528 NCCI

81252 87529 NCCI

81252 87530 NCCI

81252 87531 NCCI

81252 87532 NCCI

81252 87533 NCCI

81252 87534 NCCI

81252 87535 NCCI

81252 87536 NCCI

81252 87537 NCCI

81252 87538 NCCI

81252 87539 NCCI

81252 87540 NCCI

81252 87541 NCCI

81252 87542 NCCI

81252 87550 NCCI

81252 87551 NCCI

Comprehensive ComponentCode Code Source

81252 87552 NCCI

81252 87555 NCCI

81252 87556 NCCI

81252 87557 NCCI

81252 87560 NCCI

81252 87561 NCCI

81252 87562 NCCI

81252 87580 NCCI

81252 87581 NCCI

81252 87582 NCCI

81252 87590 NCCI

81252 87591 NCCI

81252 87592 NCCI

81252 87623 NCCI

81252 87624 NCCI

81252 87625 NCCI

81252 87631 NCCI

81252 87632 NCCI

81252 87633 NCCI

81252 87640 NCCI

81252 87641 NCCI

81252 87650 NCCI

81252 87651 NCCI

81252 87652 NCCI

81252 87653 NCCI

81252 87660 NCCI

81252 87661 NCCI

81252 87797 NCCI

81252 87798 NCCI

81252 87799 NCCI

81252 87800 NCCI

81252 87801 NCCI

81252 88271 NCCI

81252 88272 NCCI

81252 88273 NCCI

81252 88274 NCCI

81252 88275 NCCI

81252 88291 NCCI

81252 88364 NCCI

81252 88365 NCCI

81252 88366 NCCI

81252 88367 NCCI

81252 88368 NCCI

81252 88369 NCCI

81252 88373 NCCI

81252 88374 NCCI

81252 88377 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 60 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81252 G0476 NCCI

81253 80500 NCCI

81253 80502 NCCI

81253 84311 NCCI

81253 87140 NCCI

81253 87143 NCCI

81253 87147 NCCI

81253 87149 NCCI

81253 87150 NCCI

81253 87152 NCCI

81253 87153 NCCI

81253 87158 NCCI

81253 87470 NCCI

81253 87471 NCCI

81253 87472 NCCI

81253 87475 NCCI

81253 87476 NCCI

81253 87477 NCCI

81253 87480 NCCI

81253 87481 NCCI

81253 87482 NCCI

81253 87483 NCCI

81253 87485 NCCI

81253 87486 NCCI

81253 87487 NCCI

81253 87490 NCCI

81253 87491 NCCI

81253 87492 NCCI

81253 87493 NCCI

81253 87495 NCCI

81253 87496 NCCI

81253 87497 NCCI

81253 87498 NCCI

81253 87500 NCCI

81253 87501 NCCI

81253 87502 NCCI

81253 87503 NCCI

81253 87505 NCCI

81253 87506 NCCI

81253 87507 NCCI

81253 87510 NCCI

81253 87511 NCCI

81253 87512 NCCI

81253 87515 NCCI

81253 87516 NCCI

81253 87517 NCCI

81253 87520 NCCI

Comprehensive ComponentCode Code Source

81253 87521 NCCI

81253 87522 NCCI

81253 87525 NCCI

81253 87526 NCCI

81253 87527 NCCI

81253 87528 NCCI

81253 87529 NCCI

81253 87530 NCCI

81253 87531 NCCI

81253 87532 NCCI

81253 87533 NCCI

81253 87534 NCCI

81253 87535 NCCI

81253 87536 NCCI

81253 87537 NCCI

81253 87538 NCCI

81253 87539 NCCI

81253 87540 NCCI

81253 87541 NCCI

81253 87542 NCCI

81253 87550 NCCI

81253 87551 NCCI

81253 87552 NCCI

81253 87555 NCCI

81253 87556 NCCI

81253 87557 NCCI

81253 87560 NCCI

81253 87561 NCCI

81253 87562 NCCI

81253 87580 NCCI

81253 87581 NCCI

81253 87582 NCCI

81253 87590 NCCI

81253 87591 NCCI

81253 87592 NCCI

81253 87623 NCCI

81253 87624 NCCI

81253 87625 NCCI

81253 87631 NCCI

81253 87632 NCCI

81253 87633 NCCI

81253 87640 NCCI

81253 87641 NCCI

81253 87650 NCCI

81253 87651 NCCI

81253 87652 NCCI

81253 87653 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 61 of 255

Page 62: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81253 87660 NCCI

81253 87661 NCCI

81253 87797 NCCI

81253 87798 NCCI

81253 87799 NCCI

81253 87800 NCCI

81253 87801 NCCI

81253 88271 NCCI

81253 88272 NCCI

81253 88273 NCCI

81253 88274 NCCI

81253 88275 NCCI

81253 88291 NCCI

81253 88364 NCCI

81253 88365 NCCI

81253 88366 NCCI

81253 88367 NCCI

81253 88368 NCCI

81253 88369 NCCI

81253 88373 NCCI

81253 88374 NCCI

81253 88377 NCCI

81253 G0476 NCCI

81254 80500 NCCI

81254 80502 NCCI

81254 84311 NCCI

81254 87140 NCCI

81254 87143 NCCI

81254 87147 NCCI

81254 87149 NCCI

81254 87150 NCCI

81254 87152 NCCI

81254 87153 NCCI

81254 87158 NCCI

81254 87470 NCCI

81254 87471 NCCI

81254 87472 NCCI

81254 87475 NCCI

81254 87476 NCCI

81254 87477 NCCI

81254 87480 NCCI

81254 87481 NCCI

81254 87482 NCCI

81254 87483 NCCI

81254 87485 NCCI

81254 87486 NCCI

81254 87487 NCCI

Comprehensive ComponentCode Code Source

81254 87490 NCCI

81254 87491 NCCI

81254 87492 NCCI

81254 87493 NCCI

81254 87495 NCCI

81254 87496 NCCI

81254 87497 NCCI

81254 87498 NCCI

81254 87500 NCCI

81254 87501 NCCI

81254 87502 NCCI

81254 87503 NCCI

81254 87505 NCCI

81254 87506 NCCI

81254 87507 NCCI

81254 87510 NCCI

81254 87511 NCCI

81254 87512 NCCI

81254 87515 NCCI

81254 87516 NCCI

81254 87517 NCCI

81254 87520 NCCI

81254 87521 NCCI

81254 87522 NCCI

81254 87525 NCCI

81254 87526 NCCI

81254 87527 NCCI

81254 87528 NCCI

81254 87529 NCCI

81254 87530 NCCI

81254 87531 NCCI

81254 87532 NCCI

81254 87533 NCCI

81254 87534 NCCI

81254 87535 NCCI

81254 87536 NCCI

81254 87537 NCCI

81254 87538 NCCI

81254 87539 NCCI

81254 87540 NCCI

81254 87541 NCCI

81254 87542 NCCI

81254 87550 NCCI

81254 87551 NCCI

81254 87552 NCCI

81254 87555 NCCI

81254 87556 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 62 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81254 87557 NCCI

81254 87560 NCCI

81254 87561 NCCI

81254 87562 NCCI

81254 87580 NCCI

81254 87581 NCCI

81254 87582 NCCI

81254 87590 NCCI

81254 87591 NCCI

81254 87592 NCCI

81254 87623 NCCI

81254 87624 NCCI

81254 87625 NCCI

81254 87631 NCCI

81254 87632 NCCI

81254 87633 NCCI

81254 87640 NCCI

81254 87641 NCCI

81254 87650 NCCI

81254 87651 NCCI

81254 87652 NCCI

81254 87653 NCCI

81254 87660 NCCI

81254 87661 NCCI

81254 87797 NCCI

81254 87798 NCCI

81254 87799 NCCI

81254 87800 NCCI

81254 87801 NCCI

81254 88271 NCCI

81254 88272 NCCI

81254 88273 NCCI

81254 88274 NCCI

81254 88275 NCCI

81254 88291 NCCI

81254 88364 NCCI

81254 88365 NCCI

81254 88366 NCCI

81254 88367 NCCI

81254 88368 NCCI

81254 88369 NCCI

81254 88373 NCCI

81254 88374 NCCI

81254 88377 NCCI

81254 G0476 NCCI

81255 80500 NCCI

81255 80502 NCCI

Comprehensive ComponentCode Code Source

81255 84311 NCCI

81255 87140 NCCI

81255 87143 NCCI

81255 87147 NCCI

81255 87149 NCCI

81255 87150 NCCI

81255 87152 NCCI

81255 87153 NCCI

81255 87158 NCCI

81255 87470 NCCI

81255 87471 NCCI

81255 87472 NCCI

81255 87475 NCCI

81255 87476 NCCI

81255 87477 NCCI

81255 87480 NCCI

81255 87481 NCCI

81255 87482 NCCI

81255 87483 NCCI

81255 87485 NCCI

81255 87486 NCCI

81255 87487 NCCI

81255 87490 NCCI

81255 87491 NCCI

81255 87492 NCCI

81255 87493 NCCI

81255 87495 NCCI

81255 87496 NCCI

81255 87497 NCCI

81255 87498 NCCI

81255 87500 NCCI

81255 87501 NCCI

81255 87502 NCCI

81255 87503 NCCI

81255 87505 NCCI

81255 87506 NCCI

81255 87507 NCCI

81255 87510 NCCI

81255 87511 NCCI

81255 87512 NCCI

81255 87515 NCCI

81255 87516 NCCI

81255 87517 NCCI

81255 87520 NCCI

81255 87521 NCCI

81255 87522 NCCI

81255 87525 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 63 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81255 87526 NCCI

81255 87527 NCCI

81255 87528 NCCI

81255 87529 NCCI

81255 87530 NCCI

81255 87531 NCCI

81255 87532 NCCI

81255 87533 NCCI

81255 87534 NCCI

81255 87535 NCCI

81255 87536 NCCI

81255 87537 NCCI

81255 87538 NCCI

81255 87539 NCCI

81255 87540 NCCI

81255 87541 NCCI

81255 87542 NCCI

81255 87550 NCCI

81255 87551 NCCI

81255 87552 NCCI

81255 87555 NCCI

81255 87556 NCCI

81255 87557 NCCI

81255 87560 NCCI

81255 87561 NCCI

81255 87562 NCCI

81255 87580 NCCI

81255 87581 NCCI

81255 87582 NCCI

81255 87590 NCCI

81255 87591 NCCI

81255 87592 NCCI

81255 87623 NCCI

81255 87624 NCCI

81255 87625 NCCI

81255 87631 NCCI

81255 87632 NCCI

81255 87633 NCCI

81255 87640 NCCI

81255 87641 NCCI

81255 87650 NCCI

81255 87651 NCCI

81255 87652 NCCI

81255 87653 NCCI

81255 87660 NCCI

81255 87661 NCCI

81255 87797 NCCI

Comprehensive ComponentCode Code Source

81255 87798 NCCI

81255 87799 NCCI

81255 87800 NCCI

81255 87801 NCCI

81255 88271 NCCI

81255 88272 NCCI

81255 88273 NCCI

81255 88274 NCCI

81255 88275 NCCI

81255 88291 NCCI

81255 88364 NCCI

81255 88365 NCCI

81255 88366 NCCI

81255 88367 NCCI

81255 88368 NCCI

81255 88369 NCCI

81255 88373 NCCI

81255 88374 NCCI

81255 88377 NCCI

81255 G0476 NCCI

81256 80500 NCCI

81256 80502 NCCI

81256 84311 NCCI

81256 87140 NCCI

81256 87143 NCCI

81256 87147 NCCI

81256 87149 NCCI

81256 87150 NCCI

81256 87152 NCCI

81256 87153 NCCI

81256 87158 NCCI

81256 87470 NCCI

81256 87471 NCCI

81256 87472 NCCI

81256 87475 NCCI

81256 87476 NCCI

81256 87477 NCCI

81256 87480 NCCI

81256 87481 NCCI

81256 87482 NCCI

81256 87483 NCCI

81256 87485 NCCI

81256 87486 NCCI

81256 87487 NCCI

81256 87490 NCCI

81256 87491 NCCI

81256 87492 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 64 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81256 87493 NCCI

81256 87495 NCCI

81256 87496 NCCI

81256 87497 NCCI

81256 87498 NCCI

81256 87500 NCCI

81256 87501 NCCI

81256 87502 NCCI

81256 87503 NCCI

81256 87505 NCCI

81256 87506 NCCI

81256 87507 NCCI

81256 87510 NCCI

81256 87511 NCCI

81256 87512 NCCI

81256 87515 NCCI

81256 87516 NCCI

81256 87517 NCCI

81256 87520 NCCI

81256 87521 NCCI

81256 87522 NCCI

81256 87525 NCCI

81256 87526 NCCI

81256 87527 NCCI

81256 87528 NCCI

81256 87529 NCCI

81256 87530 NCCI

81256 87531 NCCI

81256 87532 NCCI

81256 87533 NCCI

81256 87534 NCCI

81256 87535 NCCI

81256 87536 NCCI

81256 87537 NCCI

81256 87538 NCCI

81256 87539 NCCI

81256 87540 NCCI

81256 87541 NCCI

81256 87542 NCCI

81256 87550 NCCI

81256 87551 NCCI

81256 87552 NCCI

81256 87555 NCCI

81256 87556 NCCI

81256 87557 NCCI

81256 87560 NCCI

81256 87561 NCCI

Comprehensive ComponentCode Code Source

81256 87562 NCCI

81256 87580 NCCI

81256 87581 NCCI

81256 87582 NCCI

81256 87590 NCCI

81256 87591 NCCI

81256 87592 NCCI

81256 87623 NCCI

81256 87624 NCCI

81256 87625 NCCI

81256 87631 NCCI

81256 87632 NCCI

81256 87633 NCCI

81256 87640 NCCI

81256 87641 NCCI

81256 87650 NCCI

81256 87651 NCCI

81256 87652 NCCI

81256 87653 NCCI

81256 87660 NCCI

81256 87661 NCCI

81256 87797 NCCI

81256 87798 NCCI

81256 87799 NCCI

81256 87800 NCCI

81256 87801 NCCI

81256 88271 NCCI

81256 88272 NCCI

81256 88273 NCCI

81256 88274 NCCI

81256 88275 NCCI

81256 88291 NCCI

81256 88364 NCCI

81256 88365 NCCI

81256 88366 NCCI

81256 88367 NCCI

81256 88368 NCCI

81256 88369 NCCI

81256 88373 NCCI

81256 88374 NCCI

81256 88377 NCCI

81256 G0476 NCCI

81257 80500 NCCI

81257 80502 NCCI

81257 84311 NCCI

81257 87140 NCCI

81257 87143 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 65 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81257 87147 NCCI

81257 87149 NCCI

81257 87150 NCCI

81257 87152 NCCI

81257 87153 NCCI

81257 87158 NCCI

81257 87470 NCCI

81257 87471 NCCI

81257 87472 NCCI

81257 87475 NCCI

81257 87476 NCCI

81257 87477 NCCI

81257 87480 NCCI

81257 87481 NCCI

81257 87482 NCCI

81257 87483 NCCI

81257 87485 NCCI

81257 87486 NCCI

81257 87487 NCCI

81257 87490 NCCI

81257 87491 NCCI

81257 87492 NCCI

81257 87493 NCCI

81257 87495 NCCI

81257 87496 NCCI

81257 87497 NCCI

81257 87498 NCCI

81257 87500 NCCI

81257 87501 NCCI

81257 87502 NCCI

81257 87503 NCCI

81257 87505 NCCI

81257 87506 NCCI

81257 87507 NCCI

81257 87510 NCCI

81257 87511 NCCI

81257 87512 NCCI

81257 87515 NCCI

81257 87516 NCCI

81257 87517 NCCI

81257 87520 NCCI

81257 87521 NCCI

81257 87522 NCCI

81257 87525 NCCI

81257 87526 NCCI

81257 87527 NCCI

81257 87528 NCCI

Comprehensive ComponentCode Code Source

81257 87529 NCCI

81257 87530 NCCI

81257 87531 NCCI

81257 87532 NCCI

81257 87533 NCCI

81257 87534 NCCI

81257 87535 NCCI

81257 87536 NCCI

81257 87537 NCCI

81257 87538 NCCI

81257 87539 NCCI

81257 87540 NCCI

81257 87541 NCCI

81257 87542 NCCI

81257 87550 NCCI

81257 87551 NCCI

81257 87552 NCCI

81257 87555 NCCI

81257 87556 NCCI

81257 87557 NCCI

81257 87560 NCCI

81257 87561 NCCI

81257 87562 NCCI

81257 87580 NCCI

81257 87581 NCCI

81257 87582 NCCI

81257 87590 NCCI

81257 87591 NCCI

81257 87592 NCCI

81257 87623 NCCI

81257 87624 NCCI

81257 87625 NCCI

81257 87631 NCCI

81257 87632 NCCI

81257 87633 NCCI

81257 87640 NCCI

81257 87641 NCCI

81257 87650 NCCI

81257 87651 NCCI

81257 87652 NCCI

81257 87653 NCCI

81257 87660 NCCI

81257 87661 NCCI

81257 87797 NCCI

81257 87798 NCCI

81257 87799 NCCI

81257 87800 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 66 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81257 87801 NCCI

81257 88271 NCCI

81257 88272 NCCI

81257 88273 NCCI

81257 88274 NCCI

81257 88275 NCCI

81257 88291 NCCI

81257 88364 NCCI

81257 88365 NCCI

81257 88366 NCCI

81257 88367 NCCI

81257 88368 NCCI

81257 88369 NCCI

81257 88373 NCCI

81257 88374 NCCI

81257 88377 NCCI

81257 G0476 NCCI

81260 80500 NCCI

81260 80502 NCCI

81260 84311 NCCI

81260 87140 NCCI

81260 87143 NCCI

81260 87147 NCCI

81260 87149 NCCI

81260 87150 NCCI

81260 87152 NCCI

81260 87153 NCCI

81260 87158 NCCI

81260 87470 NCCI

81260 87471 NCCI

81260 87472 NCCI

81260 87475 NCCI

81260 87476 NCCI

81260 87477 NCCI

81260 87480 NCCI

81260 87481 NCCI

81260 87482 NCCI

81260 87483 NCCI

81260 87485 NCCI

81260 87486 NCCI

81260 87487 NCCI

81260 87490 NCCI

81260 87491 NCCI

81260 87492 NCCI

81260 87493 NCCI

81260 87495 NCCI

81260 87496 NCCI

Comprehensive ComponentCode Code Source

81260 87497 NCCI

81260 87498 NCCI

81260 87500 NCCI

81260 87501 NCCI

81260 87502 NCCI

81260 87503 NCCI

81260 87505 NCCI

81260 87506 NCCI

81260 87507 NCCI

81260 87510 NCCI

81260 87511 NCCI

81260 87512 NCCI

81260 87515 NCCI

81260 87516 NCCI

81260 87517 NCCI

81260 87520 NCCI

81260 87521 NCCI

81260 87522 NCCI

81260 87525 NCCI

81260 87526 NCCI

81260 87527 NCCI

81260 87528 NCCI

81260 87529 NCCI

81260 87530 NCCI

81260 87531 NCCI

81260 87532 NCCI

81260 87533 NCCI

81260 87534 NCCI

81260 87535 NCCI

81260 87536 NCCI

81260 87537 NCCI

81260 87538 NCCI

81260 87539 NCCI

81260 87540 NCCI

81260 87541 NCCI

81260 87542 NCCI

81260 87550 NCCI

81260 87551 NCCI

81260 87552 NCCI

81260 87555 NCCI

81260 87556 NCCI

81260 87557 NCCI

81260 87560 NCCI

81260 87561 NCCI

81260 87562 NCCI

81260 87580 NCCI

81260 87581 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 67 of 255

Page 68: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81260 87582 NCCI

81260 87590 NCCI

81260 87591 NCCI

81260 87592 NCCI

81260 87623 NCCI

81260 87624 NCCI

81260 87625 NCCI

81260 87631 NCCI

81260 87632 NCCI

81260 87633 NCCI

81260 87640 NCCI

81260 87641 NCCI

81260 87650 NCCI

81260 87651 NCCI

81260 87652 NCCI

81260 87653 NCCI

81260 87660 NCCI

81260 87661 NCCI

81260 87797 NCCI

81260 87798 NCCI

81260 87799 NCCI

81260 87800 NCCI

81260 87801 NCCI

81260 88271 NCCI

81260 88272 NCCI

81260 88273 NCCI

81260 88274 NCCI

81260 88275 NCCI

81260 88291 NCCI

81260 88364 NCCI

81260 88365 NCCI

81260 88366 NCCI

81260 88367 NCCI

81260 88368 NCCI

81260 88369 NCCI

81260 88373 NCCI

81260 88374 NCCI

81260 88377 NCCI

81260 G0476 NCCI

81261 80500 NCCI

81261 80502 NCCI

81261 81262 NCCI

81261 81263 NCCI

81261 84311 NCCI

81261 87140 NCCI

81261 87143 NCCI

81261 87147 NCCI

Comprehensive ComponentCode Code Source

81261 87149 NCCI

81261 87150 NCCI

81261 87152 NCCI

81261 87153 NCCI

81261 87158 NCCI

81261 87470 NCCI

81261 87471 NCCI

81261 87472 NCCI

81261 87475 NCCI

81261 87476 NCCI

81261 87477 NCCI

81261 87480 NCCI

81261 87481 NCCI

81261 87482 NCCI

81261 87483 NCCI

81261 87485 NCCI

81261 87486 NCCI

81261 87487 NCCI

81261 87490 NCCI

81261 87491 NCCI

81261 87492 NCCI

81261 87493 NCCI

81261 87495 NCCI

81261 87496 NCCI

81261 87497 NCCI

81261 87498 NCCI

81261 87500 NCCI

81261 87501 NCCI

81261 87502 NCCI

81261 87503 NCCI

81261 87505 NCCI

81261 87506 NCCI

81261 87507 NCCI

81261 87510 NCCI

81261 87511 NCCI

81261 87512 NCCI

81261 87515 NCCI

81261 87516 NCCI

81261 87517 NCCI

81261 87520 NCCI

81261 87521 NCCI

81261 87522 NCCI

81261 87525 NCCI

81261 87526 NCCI

81261 87527 NCCI

81261 87528 NCCI

81261 87529 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 68 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81261 87530 NCCI

81261 87531 NCCI

81261 87532 NCCI

81261 87533 NCCI

81261 87534 NCCI

81261 87535 NCCI

81261 87536 NCCI

81261 87537 NCCI

81261 87538 NCCI

81261 87539 NCCI

81261 87540 NCCI

81261 87541 NCCI

81261 87542 NCCI

81261 87550 NCCI

81261 87551 NCCI

81261 87552 NCCI

81261 87555 NCCI

81261 87556 NCCI

81261 87557 NCCI

81261 87560 NCCI

81261 87561 NCCI

81261 87562 NCCI

81261 87580 NCCI

81261 87581 NCCI

81261 87582 NCCI

81261 87590 NCCI

81261 87591 NCCI

81261 87592 NCCI

81261 87623 NCCI

81261 87624 NCCI

81261 87625 NCCI

81261 87631 NCCI

81261 87632 NCCI

81261 87633 NCCI

81261 87640 NCCI

81261 87641 NCCI

81261 87650 NCCI

81261 87651 NCCI

81261 87652 NCCI

81261 87653 NCCI

81261 87660 NCCI

81261 87661 NCCI

81261 87797 NCCI

81261 87798 NCCI

81261 87799 NCCI

81261 87800 NCCI

81261 87801 NCCI

Comprehensive ComponentCode Code Source

81261 88271 NCCI

81261 88272 NCCI

81261 88273 NCCI

81261 88274 NCCI

81261 88275 NCCI

81261 88291 NCCI

81261 88364 NCCI

81261 88365 NCCI

81261 88366 NCCI

81261 88367 NCCI

81261 88368 NCCI

81261 88369 NCCI

81261 88373 NCCI

81261 88374 NCCI

81261 88377 NCCI

81261 G0476 NCCI

81262 80500 NCCI

81262 80502 NCCI

81262 81263 NCCI

81262 84311 NCCI

81262 87140 NCCI

81262 87143 NCCI

81262 87147 NCCI

81262 87149 NCCI

81262 87150 NCCI

81262 87152 NCCI

81262 87153 NCCI

81262 87158 NCCI

81262 87470 NCCI

81262 87471 NCCI

81262 87472 NCCI

81262 87475 NCCI

81262 87476 NCCI

81262 87477 NCCI

81262 87480 NCCI

81262 87481 NCCI

81262 87482 NCCI

81262 87483 NCCI

81262 87485 NCCI

81262 87486 NCCI

81262 87487 NCCI

81262 87490 NCCI

81262 87491 NCCI

81262 87492 NCCI

81262 87493 NCCI

81262 87495 NCCI

81262 87496 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 69 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81262 87497 NCCI

81262 87498 NCCI

81262 87500 NCCI

81262 87501 NCCI

81262 87502 NCCI

81262 87503 NCCI

81262 87505 NCCI

81262 87506 NCCI

81262 87507 NCCI

81262 87510 NCCI

81262 87511 NCCI

81262 87512 NCCI

81262 87515 NCCI

81262 87516 NCCI

81262 87517 NCCI

81262 87520 NCCI

81262 87521 NCCI

81262 87522 NCCI

81262 87525 NCCI

81262 87526 NCCI

81262 87527 NCCI

81262 87528 NCCI

81262 87529 NCCI

81262 87530 NCCI

81262 87531 NCCI

81262 87532 NCCI

81262 87533 NCCI

81262 87534 NCCI

81262 87535 NCCI

81262 87536 NCCI

81262 87537 NCCI

81262 87538 NCCI

81262 87539 NCCI

81262 87540 NCCI

81262 87541 NCCI

81262 87542 NCCI

81262 87550 NCCI

81262 87551 NCCI

81262 87552 NCCI

81262 87555 NCCI

81262 87556 NCCI

81262 87557 NCCI

81262 87560 NCCI

81262 87561 NCCI

81262 87562 NCCI

81262 87580 NCCI

81262 87581 NCCI

Comprehensive ComponentCode Code Source

81262 87582 NCCI

81262 87590 NCCI

81262 87591 NCCI

81262 87592 NCCI

81262 87623 NCCI

81262 87624 NCCI

81262 87625 NCCI

81262 87631 NCCI

81262 87632 NCCI

81262 87633 NCCI

81262 87640 NCCI

81262 87641 NCCI

81262 87650 NCCI

81262 87651 NCCI

81262 87652 NCCI

81262 87653 NCCI

81262 87660 NCCI

81262 87661 NCCI

81262 87797 NCCI

81262 87798 NCCI

81262 87799 NCCI

81262 87800 NCCI

81262 87801 NCCI

81262 88271 NCCI

81262 88272 NCCI

81262 88273 NCCI

81262 88274 NCCI

81262 88275 NCCI

81262 88291 NCCI

81262 88364 NCCI

81262 88365 NCCI

81262 88366 NCCI

81262 88367 NCCI

81262 88368 NCCI

81262 88369 NCCI

81262 88373 NCCI

81262 88374 NCCI

81262 88377 NCCI

81262 G0476 NCCI

81263 80500 NCCI

81263 80502 NCCI

81263 84311 NCCI

81263 87140 NCCI

81263 87143 NCCI

81263 87147 NCCI

81263 87149 NCCI

81263 87150 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 70 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81263 87152 NCCI

81263 87153 NCCI

81263 87158 NCCI

81263 87470 NCCI

81263 87471 NCCI

81263 87472 NCCI

81263 87475 NCCI

81263 87476 NCCI

81263 87477 NCCI

81263 87480 NCCI

81263 87481 NCCI

81263 87482 NCCI

81263 87483 NCCI

81263 87485 NCCI

81263 87486 NCCI

81263 87487 NCCI

81263 87490 NCCI

81263 87491 NCCI

81263 87492 NCCI

81263 87493 NCCI

81263 87495 NCCI

81263 87496 NCCI

81263 87497 NCCI

81263 87498 NCCI

81263 87500 NCCI

81263 87501 NCCI

81263 87502 NCCI

81263 87503 NCCI

81263 87505 NCCI

81263 87506 NCCI

81263 87507 NCCI

81263 87510 NCCI

81263 87511 NCCI

81263 87512 NCCI

81263 87515 NCCI

81263 87516 NCCI

81263 87517 NCCI

81263 87520 NCCI

81263 87521 NCCI

81263 87522 NCCI

81263 87525 NCCI

81263 87526 NCCI

81263 87527 NCCI

81263 87528 NCCI

81263 87529 NCCI

81263 87530 NCCI

81263 87531 NCCI

Comprehensive ComponentCode Code Source

81263 87532 NCCI

81263 87533 NCCI

81263 87534 NCCI

81263 87535 NCCI

81263 87536 NCCI

81263 87537 NCCI

81263 87538 NCCI

81263 87539 NCCI

81263 87540 NCCI

81263 87541 NCCI

81263 87542 NCCI

81263 87550 NCCI

81263 87551 NCCI

81263 87552 NCCI

81263 87555 NCCI

81263 87556 NCCI

81263 87557 NCCI

81263 87560 NCCI

81263 87561 NCCI

81263 87562 NCCI

81263 87580 NCCI

81263 87581 NCCI

81263 87582 NCCI

81263 87590 NCCI

81263 87591 NCCI

81263 87592 NCCI

81263 87623 NCCI

81263 87624 NCCI

81263 87625 NCCI

81263 87631 NCCI

81263 87632 NCCI

81263 87633 NCCI

81263 87640 NCCI

81263 87641 NCCI

81263 87650 NCCI

81263 87651 NCCI

81263 87652 NCCI

81263 87653 NCCI

81263 87660 NCCI

81263 87661 NCCI

81263 87797 NCCI

81263 87798 NCCI

81263 87799 NCCI

81263 87800 NCCI

81263 87801 NCCI

81263 88271 NCCI

81263 88272 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 71 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81263 88273 NCCI

81263 88274 NCCI

81263 88275 NCCI

81263 88291 NCCI

81263 88364 NCCI

81263 88365 NCCI

81263 88366 NCCI

81263 88367 NCCI

81263 88368 NCCI

81263 88369 NCCI

81263 88373 NCCI

81263 88374 NCCI

81263 88377 NCCI

81263 G0476 NCCI

81264 80500 NCCI

81264 80502 NCCI

81264 84311 NCCI

81264 87140 NCCI

81264 87143 NCCI

81264 87147 NCCI

81264 87149 NCCI

81264 87150 NCCI

81264 87152 NCCI

81264 87153 NCCI

81264 87158 NCCI

81264 87470 NCCI

81264 87471 NCCI

81264 87472 NCCI

81264 87475 NCCI

81264 87476 NCCI

81264 87477 NCCI

81264 87480 NCCI

81264 87481 NCCI

81264 87482 NCCI

81264 87483 NCCI

81264 87485 NCCI

81264 87486 NCCI

81264 87487 NCCI

81264 87490 NCCI

81264 87491 NCCI

81264 87492 NCCI

81264 87493 NCCI

81264 87495 NCCI

81264 87496 NCCI

81264 87497 NCCI

81264 87498 NCCI

81264 87500 NCCI

Comprehensive ComponentCode Code Source

81264 87501 NCCI

81264 87502 NCCI

81264 87503 NCCI

81264 87505 NCCI

81264 87506 NCCI

81264 87507 NCCI

81264 87510 NCCI

81264 87511 NCCI

81264 87512 NCCI

81264 87515 NCCI

81264 87516 NCCI

81264 87517 NCCI

81264 87520 NCCI

81264 87521 NCCI

81264 87522 NCCI

81264 87525 NCCI

81264 87526 NCCI

81264 87527 NCCI

81264 87528 NCCI

81264 87529 NCCI

81264 87530 NCCI

81264 87531 NCCI

81264 87532 NCCI

81264 87533 NCCI

81264 87534 NCCI

81264 87535 NCCI

81264 87536 NCCI

81264 87537 NCCI

81264 87538 NCCI

81264 87539 NCCI

81264 87540 NCCI

81264 87541 NCCI

81264 87542 NCCI

81264 87550 NCCI

81264 87551 NCCI

81264 87552 NCCI

81264 87555 NCCI

81264 87556 NCCI

81264 87557 NCCI

81264 87560 NCCI

81264 87561 NCCI

81264 87562 NCCI

81264 87580 NCCI

81264 87581 NCCI

81264 87582 NCCI

81264 87590 NCCI

81264 87591 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 72 of 255

Page 73: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81264 87592 NCCI

81264 87623 NCCI

81264 87624 NCCI

81264 87625 NCCI

81264 87631 NCCI

81264 87632 NCCI

81264 87633 NCCI

81264 87640 NCCI

81264 87641 NCCI

81264 87650 NCCI

81264 87651 NCCI

81264 87652 NCCI

81264 87653 NCCI

81264 87660 NCCI

81264 87661 NCCI

81264 87797 NCCI

81264 87798 NCCI

81264 87799 NCCI

81264 87800 NCCI

81264 87801 NCCI

81264 88271 NCCI

81264 88272 NCCI

81264 88273 NCCI

81264 88274 NCCI

81264 88275 NCCI

81264 88291 NCCI

81264 88364 NCCI

81264 88365 NCCI

81264 88366 NCCI

81264 88367 NCCI

81264 88368 NCCI

81264 88369 NCCI

81264 88373 NCCI

81264 88374 NCCI

81264 88377 NCCI

81264 G0476 NCCI

81265 80500 NCCI

81265 80502 NCCI

81265 84311 NCCI

81265 87140 NCCI

81265 87143 NCCI

81265 87147 NCCI

81265 87149 NCCI

81265 87150 NCCI

81265 87152 NCCI

81265 87153 NCCI

81265 87158 NCCI

Comprehensive ComponentCode Code Source

81265 87470 NCCI

81265 87471 NCCI

81265 87472 NCCI

81265 87475 NCCI

81265 87476 NCCI

81265 87477 NCCI

81265 87480 NCCI

81265 87481 NCCI

81265 87482 NCCI

81265 87483 NCCI

81265 87485 NCCI

81265 87486 NCCI

81265 87487 NCCI

81265 87490 NCCI

81265 87491 NCCI

81265 87492 NCCI

81265 87493 NCCI

81265 87495 NCCI

81265 87496 NCCI

81265 87497 NCCI

81265 87498 NCCI

81265 87500 NCCI

81265 87501 NCCI

81265 87502 NCCI

81265 87503 NCCI

81265 87505 NCCI

81265 87506 NCCI

81265 87507 NCCI

81265 87510 NCCI

81265 87511 NCCI

81265 87512 NCCI

81265 87515 NCCI

81265 87516 NCCI

81265 87517 NCCI

81265 87520 NCCI

81265 87521 NCCI

81265 87522 NCCI

81265 87525 NCCI

81265 87526 NCCI

81265 87527 NCCI

81265 87528 NCCI

81265 87529 NCCI

81265 87530 NCCI

81265 87531 NCCI

81265 87532 NCCI

81265 87533 NCCI

81265 87534 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 73 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81265 87535 NCCI

81265 87536 NCCI

81265 87537 NCCI

81265 87538 NCCI

81265 87539 NCCI

81265 87540 NCCI

81265 87541 NCCI

81265 87542 NCCI

81265 87550 NCCI

81265 87551 NCCI

81265 87552 NCCI

81265 87555 NCCI

81265 87556 NCCI

81265 87557 NCCI

81265 87560 NCCI

81265 87561 NCCI

81265 87562 NCCI

81265 87580 NCCI

81265 87581 NCCI

81265 87582 NCCI

81265 87590 NCCI

81265 87591 NCCI

81265 87592 NCCI

81265 87623 NCCI

81265 87624 NCCI

81265 87625 NCCI

81265 87631 NCCI

81265 87632 NCCI

81265 87633 NCCI

81265 87640 NCCI

81265 87641 NCCI

81265 87650 NCCI

81265 87651 NCCI

81265 87652 NCCI

81265 87653 NCCI

81265 87660 NCCI

81265 87661 NCCI

81265 87797 NCCI

81265 87798 NCCI

81265 87799 NCCI

81265 87800 NCCI

81265 87801 NCCI

81265 88291 NCCI

81265 88364 NCCI

81265 88369 NCCI

81265 88373 NCCI

81265 G0476 NCCI

Comprehensive ComponentCode Code Source

81266 80500 NCCI

81266 80502 NCCI

81266 84311 NCCI

81266 87140 NCCI

81266 87143 NCCI

81266 87147 NCCI

81266 87149 NCCI

81266 87150 NCCI

81266 87152 NCCI

81266 87153 NCCI

81266 87158 NCCI

81266 87470 NCCI

81266 87471 NCCI

81266 87472 NCCI

81266 87475 NCCI

81266 87476 NCCI

81266 87477 NCCI

81266 87480 NCCI

81266 87481 NCCI

81266 87482 NCCI

81266 87483 NCCI

81266 87485 NCCI

81266 87486 NCCI

81266 87487 NCCI

81266 87490 NCCI

81266 87491 NCCI

81266 87492 NCCI

81266 87493 NCCI

81266 87495 NCCI

81266 87496 NCCI

81266 87497 NCCI

81266 87498 NCCI

81266 87500 NCCI

81266 87501 NCCI

81266 87502 NCCI

81266 87503 NCCI

81266 87505 NCCI

81266 87506 NCCI

81266 87507 NCCI

81266 87510 NCCI

81266 87511 NCCI

81266 87512 NCCI

81266 87515 NCCI

81266 87516 NCCI

81266 87517 NCCI

81266 87520 NCCI

81266 87521 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 74 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81266 87522 NCCI

81266 87525 NCCI

81266 87526 NCCI

81266 87527 NCCI

81266 87528 NCCI

81266 87529 NCCI

81266 87530 NCCI

81266 87531 NCCI

81266 87532 NCCI

81266 87533 NCCI

81266 87534 NCCI

81266 87535 NCCI

81266 87536 NCCI

81266 87537 NCCI

81266 87538 NCCI

81266 87539 NCCI

81266 87540 NCCI

81266 87541 NCCI

81266 87542 NCCI

81266 87550 NCCI

81266 87551 NCCI

81266 87552 NCCI

81266 87555 NCCI

81266 87556 NCCI

81266 87557 NCCI

81266 87560 NCCI

81266 87561 NCCI

81266 87562 NCCI

81266 87580 NCCI

81266 87581 NCCI

81266 87582 NCCI

81266 87590 NCCI

81266 87591 NCCI

81266 87592 NCCI

81266 87623 NCCI

81266 87624 NCCI

81266 87625 NCCI

81266 87631 NCCI

81266 87632 NCCI

81266 87633 NCCI

81266 87640 NCCI

81266 87641 NCCI

81266 87650 NCCI

81266 87651 NCCI

81266 87652 NCCI

81266 87653 NCCI

81266 87660 NCCI

Comprehensive ComponentCode Code Source

81266 87661 NCCI

81266 87797 NCCI

81266 87798 NCCI

81266 87799 NCCI

81266 87800 NCCI

81266 87801 NCCI

81266 88291 NCCI

81266 88364 NCCI

81266 88369 NCCI

81266 88373 NCCI

81266 G0476 NCCI

81267 80500 NCCI

81267 80502 NCCI

81267 84311 NCCI

81267 87140 NCCI

81267 87143 NCCI

81267 87147 NCCI

81267 87149 NCCI

81267 87150 NCCI

81267 87152 NCCI

81267 87153 NCCI

81267 87158 NCCI

81267 87470 NCCI

81267 87471 NCCI

81267 87472 NCCI

81267 87475 NCCI

81267 87476 NCCI

81267 87477 NCCI

81267 87480 NCCI

81267 87481 NCCI

81267 87482 NCCI

81267 87483 NCCI

81267 87485 NCCI

81267 87486 NCCI

81267 87487 NCCI

81267 87490 NCCI

81267 87491 NCCI

81267 87492 NCCI

81267 87493 NCCI

81267 87495 NCCI

81267 87496 NCCI

81267 87497 NCCI

81267 87498 NCCI

81267 87500 NCCI

81267 87501 NCCI

81267 87502 NCCI

81267 87503 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 75 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81267 87505 NCCI

81267 87506 NCCI

81267 87507 NCCI

81267 87510 NCCI

81267 87511 NCCI

81267 87512 NCCI

81267 87515 NCCI

81267 87516 NCCI

81267 87517 NCCI

81267 87520 NCCI

81267 87521 NCCI

81267 87522 NCCI

81267 87525 NCCI

81267 87526 NCCI

81267 87527 NCCI

81267 87528 NCCI

81267 87529 NCCI

81267 87530 NCCI

81267 87531 NCCI

81267 87532 NCCI

81267 87533 NCCI

81267 87534 NCCI

81267 87535 NCCI

81267 87536 NCCI

81267 87537 NCCI

81267 87538 NCCI

81267 87539 NCCI

81267 87540 NCCI

81267 87541 NCCI

81267 87542 NCCI

81267 87550 NCCI

81267 87551 NCCI

81267 87552 NCCI

81267 87555 NCCI

81267 87556 NCCI

81267 87557 NCCI

81267 87560 NCCI

81267 87561 NCCI

81267 87562 NCCI

81267 87580 NCCI

81267 87581 NCCI

81267 87582 NCCI

81267 87590 NCCI

81267 87591 NCCI

81267 87592 NCCI

81267 87623 NCCI

81267 87624 NCCI

Comprehensive ComponentCode Code Source

81267 87625 NCCI

81267 87631 NCCI

81267 87632 NCCI

81267 87633 NCCI

81267 87640 NCCI

81267 87641 NCCI

81267 87650 NCCI

81267 87651 NCCI

81267 87652 NCCI

81267 87653 NCCI

81267 87660 NCCI

81267 87661 NCCI

81267 87797 NCCI

81267 87798 NCCI

81267 87799 NCCI

81267 87800 NCCI

81267 87801 NCCI

81267 88291 NCCI

81267 88364 NCCI

81267 88369 NCCI

81267 88373 NCCI

81267 G0476 NCCI

81268 80500 NCCI

81268 80502 NCCI

81268 81267 NCCI

81268 84311 NCCI

81268 87140 NCCI

81268 87143 NCCI

81268 87147 NCCI

81268 87149 NCCI

81268 87150 NCCI

81268 87152 NCCI

81268 87153 NCCI

81268 87158 NCCI

81268 87470 NCCI

81268 87471 NCCI

81268 87472 NCCI

81268 87475 NCCI

81268 87476 NCCI

81268 87477 NCCI

81268 87480 NCCI

81268 87481 NCCI

81268 87482 NCCI

81268 87483 NCCI

81268 87485 NCCI

81268 87486 NCCI

81268 87487 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 76 of 255

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Comprehensive ComponentCode Code Source

81268 87490 NCCI

81268 87491 NCCI

81268 87492 NCCI

81268 87493 NCCI

81268 87495 NCCI

81268 87496 NCCI

81268 87497 NCCI

81268 87498 NCCI

81268 87500 NCCI

81268 87501 NCCI

81268 87502 NCCI

81268 87503 NCCI

81268 87505 NCCI

81268 87506 NCCI

81268 87507 NCCI

81268 87510 NCCI

81268 87511 NCCI

81268 87512 NCCI

81268 87515 NCCI

81268 87516 NCCI

81268 87517 NCCI

81268 87520 NCCI

81268 87521 NCCI

81268 87522 NCCI

81268 87525 NCCI

81268 87526 NCCI

81268 87527 NCCI

81268 87528 NCCI

81268 87529 NCCI

81268 87530 NCCI

81268 87531 NCCI

81268 87532 NCCI

81268 87533 NCCI

81268 87534 NCCI

81268 87535 NCCI

81268 87536 NCCI

81268 87537 NCCI

81268 87538 NCCI

81268 87539 NCCI

81268 87540 NCCI

81268 87541 NCCI

81268 87542 NCCI

81268 87550 NCCI

81268 87551 NCCI

81268 87552 NCCI

81268 87555 NCCI

81268 87556 NCCI

Comprehensive ComponentCode Code Source

81268 87557 NCCI

81268 87560 NCCI

81268 87561 NCCI

81268 87562 NCCI

81268 87580 NCCI

81268 87581 NCCI

81268 87582 NCCI

81268 87590 NCCI

81268 87591 NCCI

81268 87592 NCCI

81268 87623 NCCI

81268 87624 NCCI

81268 87625 NCCI

81268 87631 NCCI

81268 87632 NCCI

81268 87633 NCCI

81268 87640 NCCI

81268 87641 NCCI

81268 87650 NCCI

81268 87651 NCCI

81268 87652 NCCI

81268 87653 NCCI

81268 87660 NCCI

81268 87661 NCCI

81268 87797 NCCI

81268 87798 NCCI

81268 87799 NCCI

81268 87800 NCCI

81268 87801 NCCI

81268 88291 NCCI

81268 88364 NCCI

81268 88369 NCCI

81268 88373 NCCI

81268 G0476 NCCI

81270 80500 NCCI

81270 80502 NCCI

81270 84311 NCCI

81270 87140 NCCI

81270 87143 NCCI

81270 87147 NCCI

81270 87149 NCCI

81270 87150 NCCI

81270 87152 NCCI

81270 87153 NCCI

81270 87158 NCCI

81270 87470 NCCI

81270 87471 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 77 of 255

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Comprehensive ComponentCode Code Source

81270 87472 NCCI

81270 87475 NCCI

81270 87476 NCCI

81270 87477 NCCI

81270 87480 NCCI

81270 87481 NCCI

81270 87482 NCCI

81270 87483 NCCI

81270 87485 NCCI

81270 87486 NCCI

81270 87487 NCCI

81270 87490 NCCI

81270 87491 NCCI

81270 87492 NCCI

81270 87493 NCCI

81270 87495 NCCI

81270 87496 NCCI

81270 87497 NCCI

81270 87498 NCCI

81270 87500 NCCI

81270 87501 NCCI

81270 87502 NCCI

81270 87503 NCCI

81270 87505 NCCI

81270 87506 NCCI

81270 87507 NCCI

81270 87510 NCCI

81270 87511 NCCI

81270 87512 NCCI

81270 87515 NCCI

81270 87516 NCCI

81270 87517 NCCI

81270 87520 NCCI

81270 87521 NCCI

81270 87522 NCCI

81270 87525 NCCI

81270 87526 NCCI

81270 87527 NCCI

81270 87528 NCCI

81270 87529 NCCI

81270 87530 NCCI

81270 87531 NCCI

81270 87532 NCCI

81270 87533 NCCI

81270 87534 NCCI

81270 87535 NCCI

81270 87536 NCCI

Comprehensive ComponentCode Code Source

81270 87537 NCCI

81270 87538 NCCI

81270 87539 NCCI

81270 87540 NCCI

81270 87541 NCCI

81270 87542 NCCI

81270 87550 NCCI

81270 87551 NCCI

81270 87552 NCCI

81270 87555 NCCI

81270 87556 NCCI

81270 87557 NCCI

81270 87560 NCCI

81270 87561 NCCI

81270 87562 NCCI

81270 87580 NCCI

81270 87581 NCCI

81270 87582 NCCI

81270 87590 NCCI

81270 87591 NCCI

81270 87592 NCCI

81270 87623 NCCI

81270 87624 NCCI

81270 87625 NCCI

81270 87631 NCCI

81270 87632 NCCI

81270 87633 NCCI

81270 87640 NCCI

81270 87641 NCCI

81270 87650 NCCI

81270 87651 NCCI

81270 87652 NCCI

81270 87653 NCCI

81270 87660 NCCI

81270 87661 NCCI

81270 87797 NCCI

81270 87798 NCCI

81270 87799 NCCI

81270 87800 NCCI

81270 87801 NCCI

81270 88271 NCCI

81270 88272 NCCI

81270 88273 NCCI

81270 88274 NCCI

81270 88275 NCCI

81270 88291 NCCI

81270 88364 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 78 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81270 88365 NCCI

81270 88366 NCCI

81270 88367 NCCI

81270 88368 NCCI

81270 88369 NCCI

81270 88373 NCCI

81270 88374 NCCI

81270 88377 NCCI

81270 G0476 NCCI

81272 80500 NCCI

81272 80502 NCCI

81272 84311 NCCI

81272 87140 NCCI

81272 87143 NCCI

81272 87147 NCCI

81272 87149 NCCI

81272 87150 NCCI

81272 87152 NCCI

81272 87153 NCCI

81272 87158 NCCI

81272 87470 NCCI

81272 87471 NCCI

81272 87472 NCCI

81272 87475 NCCI

81272 87476 NCCI

81272 87477 NCCI

81272 87480 NCCI

81272 87481 NCCI

81272 87482 NCCI

81272 87483 NCCI

81272 87485 NCCI

81272 87486 NCCI

81272 87487 NCCI

81272 87490 NCCI

81272 87491 NCCI

81272 87492 NCCI

81272 87493 NCCI

81272 87495 NCCI

81272 87496 NCCI

81272 87497 NCCI

81272 87498 NCCI

81272 87500 NCCI

81272 87501 NCCI

81272 87502 NCCI

81272 87503 NCCI

81272 87505 NCCI

81272 87506 NCCI

Comprehensive ComponentCode Code Source

81272 87507 NCCI

81272 87510 NCCI

81272 87511 NCCI

81272 87512 NCCI

81272 87515 NCCI

81272 87516 NCCI

81272 87517 NCCI

81272 87520 NCCI

81272 87521 NCCI

81272 87522 NCCI

81272 87525 NCCI

81272 87526 NCCI

81272 87527 NCCI

81272 87528 NCCI

81272 87529 NCCI

81272 87530 NCCI

81272 87531 NCCI

81272 87532 NCCI

81272 87533 NCCI

81272 87534 NCCI

81272 87535 NCCI

81272 87536 NCCI

81272 87537 NCCI

81272 87538 NCCI

81272 87539 NCCI

81272 87540 NCCI

81272 87541 NCCI

81272 87542 NCCI

81272 87550 NCCI

81272 87551 NCCI

81272 87552 NCCI

81272 87555 NCCI

81272 87556 NCCI

81272 87557 NCCI

81272 87560 NCCI

81272 87561 NCCI

81272 87562 NCCI

81272 87580 NCCI

81272 87581 NCCI

81272 87582 NCCI

81272 87590 NCCI

81272 87591 NCCI

81272 87592 NCCI

81272 87623 NCCI

81272 87624 NCCI

81272 87625 NCCI

81272 87631 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 79 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81272 87632 NCCI

81272 87633 NCCI

81272 87640 NCCI

81272 87641 NCCI

81272 87650 NCCI

81272 87651 NCCI

81272 87652 NCCI

81272 87653 NCCI

81272 87660 NCCI

81272 87661 NCCI

81272 87797 NCCI

81272 87798 NCCI

81272 87799 NCCI

81272 87800 NCCI

81272 87801 NCCI

81272 88271 NCCI

81272 88272 NCCI

81272 88273 NCCI

81272 88274 NCCI

81272 88275 NCCI

81272 88291 NCCI

81272 88364 NCCI

81272 88365 NCCI

81272 88366 NCCI

81272 88367 NCCI

81272 88368 NCCI

81272 88369 NCCI

81272 88373 NCCI

81272 88374 NCCI

81272 88377 NCCI

81272 G0476 NCCI

81273 80500 NCCI

81273 80502 NCCI

81273 84311 NCCI

81273 87140 NCCI

81273 87143 NCCI

81273 87147 NCCI

81273 87149 NCCI

81273 87150 NCCI

81273 87152 NCCI

81273 87153 NCCI

81273 87158 NCCI

81273 87470 NCCI

81273 87471 NCCI

81273 87472 NCCI

81273 87475 NCCI

81273 87476 NCCI

Comprehensive ComponentCode Code Source

81273 87477 NCCI

81273 87480 NCCI

81273 87481 NCCI

81273 87482 NCCI

81273 87483 NCCI

81273 87485 NCCI

81273 87486 NCCI

81273 87487 NCCI

81273 87490 NCCI

81273 87491 NCCI

81273 87492 NCCI

81273 87493 NCCI

81273 87495 NCCI

81273 87496 NCCI

81273 87497 NCCI

81273 87498 NCCI

81273 87500 NCCI

81273 87501 NCCI

81273 87502 NCCI

81273 87503 NCCI

81273 87505 NCCI

81273 87506 NCCI

81273 87507 NCCI

81273 87510 NCCI

81273 87511 NCCI

81273 87512 NCCI

81273 87515 NCCI

81273 87516 NCCI

81273 87517 NCCI

81273 87520 NCCI

81273 87521 NCCI

81273 87522 NCCI

81273 87525 NCCI

81273 87526 NCCI

81273 87527 NCCI

81273 87528 NCCI

81273 87529 NCCI

81273 87530 NCCI

81273 87531 NCCI

81273 87532 NCCI

81273 87533 NCCI

81273 87534 NCCI

81273 87535 NCCI

81273 87536 NCCI

81273 87537 NCCI

81273 87538 NCCI

81273 87539 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 80 of 255

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Comprehensive ComponentCode Code Source

81273 87540 NCCI

81273 87541 NCCI

81273 87542 NCCI

81273 87550 NCCI

81273 87551 NCCI

81273 87552 NCCI

81273 87555 NCCI

81273 87556 NCCI

81273 87557 NCCI

81273 87560 NCCI

81273 87561 NCCI

81273 87562 NCCI

81273 87580 NCCI

81273 87581 NCCI

81273 87582 NCCI

81273 87590 NCCI

81273 87591 NCCI

81273 87592 NCCI

81273 87623 NCCI

81273 87624 NCCI

81273 87625 NCCI

81273 87631 NCCI

81273 87632 NCCI

81273 87633 NCCI

81273 87640 NCCI

81273 87641 NCCI

81273 87650 NCCI

81273 87651 NCCI

81273 87652 NCCI

81273 87653 NCCI

81273 87660 NCCI

81273 87661 NCCI

81273 87797 NCCI

81273 87798 NCCI

81273 87799 NCCI

81273 87800 NCCI

81273 87801 NCCI

81273 88271 NCCI

81273 88272 NCCI

81273 88273 NCCI

81273 88274 NCCI

81273 88275 NCCI

81273 88291 NCCI

81273 88364 NCCI

81273 88365 NCCI

81273 88366 NCCI

81273 88367 NCCI

Comprehensive ComponentCode Code Source

81273 88368 NCCI

81273 88369 NCCI

81273 88373 NCCI

81273 88374 NCCI

81273 88377 NCCI

81273 G0476 NCCI

81275 80500 NCCI

81275 80502 NCCI

81275 84311 NCCI

81275 87140 NCCI

81275 87143 NCCI

81275 87147 NCCI

81275 87149 NCCI

81275 87150 NCCI

81275 87152 NCCI

81275 87153 NCCI

81275 87158 NCCI

81275 87470 NCCI

81275 87471 NCCI

81275 87472 NCCI

81275 87475 NCCI

81275 87476 NCCI

81275 87477 NCCI

81275 87480 NCCI

81275 87481 NCCI

81275 87482 NCCI

81275 87483 NCCI

81275 87485 NCCI

81275 87486 NCCI

81275 87487 NCCI

81275 87490 NCCI

81275 87491 NCCI

81275 87492 NCCI

81275 87493 NCCI

81275 87495 NCCI

81275 87496 NCCI

81275 87497 NCCI

81275 87498 NCCI

81275 87500 NCCI

81275 87501 NCCI

81275 87502 NCCI

81275 87503 NCCI

81275 87505 NCCI

81275 87506 NCCI

81275 87507 NCCI

81275 87510 NCCI

81275 87511 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 81 of 255

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Comprehensive ComponentCode Code Source

81275 87512 NCCI

81275 87515 NCCI

81275 87516 NCCI

81275 87517 NCCI

81275 87520 NCCI

81275 87521 NCCI

81275 87522 NCCI

81275 87525 NCCI

81275 87526 NCCI

81275 87527 NCCI

81275 87528 NCCI

81275 87529 NCCI

81275 87530 NCCI

81275 87531 NCCI

81275 87532 NCCI

81275 87533 NCCI

81275 87534 NCCI

81275 87535 NCCI

81275 87536 NCCI

81275 87537 NCCI

81275 87538 NCCI

81275 87539 NCCI

81275 87540 NCCI

81275 87541 NCCI

81275 87542 NCCI

81275 87550 NCCI

81275 87551 NCCI

81275 87552 NCCI

81275 87555 NCCI

81275 87556 NCCI

81275 87557 NCCI

81275 87560 NCCI

81275 87561 NCCI

81275 87562 NCCI

81275 87580 NCCI

81275 87581 NCCI

81275 87582 NCCI

81275 87590 NCCI

81275 87591 NCCI

81275 87592 NCCI

81275 87623 NCCI

81275 87624 NCCI

81275 87625 NCCI

81275 87631 NCCI

81275 87632 NCCI

81275 87633 NCCI

81275 87640 NCCI

Comprehensive ComponentCode Code Source

81275 87641 NCCI

81275 87650 NCCI

81275 87651 NCCI

81275 87652 NCCI

81275 87653 NCCI

81275 87660 NCCI

81275 87661 NCCI

81275 87797 NCCI

81275 87798 NCCI

81275 87799 NCCI

81275 87800 NCCI

81275 87801 NCCI

81275 88271 NCCI

81275 88272 NCCI

81275 88273 NCCI

81275 88274 NCCI

81275 88275 NCCI

81275 88291 NCCI

81275 88364 NCCI

81275 88365 NCCI

81275 88366 NCCI

81275 88367 NCCI

81275 88368 NCCI

81275 88369 NCCI

81275 88373 NCCI

81275 88374 NCCI

81275 88377 NCCI

81275 G0476 NCCI

81276 80500 NCCI

81276 80502 NCCI

81276 84311 NCCI

81276 87140 NCCI

81276 87143 NCCI

81276 87147 NCCI

81276 87149 NCCI

81276 87150 NCCI

81276 87152 NCCI

81276 87153 NCCI

81276 87158 NCCI

81276 87470 NCCI

81276 87471 NCCI

81276 87472 NCCI

81276 87475 NCCI

81276 87476 NCCI

81276 87477 NCCI

81276 87480 NCCI

81276 87481 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 82 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81276 87482 NCCI

81276 87483 NCCI

81276 87485 NCCI

81276 87486 NCCI

81276 87487 NCCI

81276 87490 NCCI

81276 87491 NCCI

81276 87492 NCCI

81276 87493 NCCI

81276 87495 NCCI

81276 87496 NCCI

81276 87497 NCCI

81276 87498 NCCI

81276 87500 NCCI

81276 87501 NCCI

81276 87502 NCCI

81276 87503 NCCI

81276 87505 NCCI

81276 87506 NCCI

81276 87507 NCCI

81276 87510 NCCI

81276 87511 NCCI

81276 87512 NCCI

81276 87515 NCCI

81276 87516 NCCI

81276 87517 NCCI

81276 87520 NCCI

81276 87521 NCCI

81276 87522 NCCI

81276 87525 NCCI

81276 87526 NCCI

81276 87527 NCCI

81276 87528 NCCI

81276 87529 NCCI

81276 87530 NCCI

81276 87531 NCCI

81276 87532 NCCI

81276 87533 NCCI

81276 87534 NCCI

81276 87535 NCCI

81276 87536 NCCI

81276 87537 NCCI

81276 87538 NCCI

81276 87539 NCCI

81276 87540 NCCI

81276 87541 NCCI

81276 87542 NCCI

Comprehensive ComponentCode Code Source

81276 87550 NCCI

81276 87551 NCCI

81276 87552 NCCI

81276 87555 NCCI

81276 87556 NCCI

81276 87557 NCCI

81276 87560 NCCI

81276 87561 NCCI

81276 87562 NCCI

81276 87580 NCCI

81276 87581 NCCI

81276 87582 NCCI

81276 87590 NCCI

81276 87591 NCCI

81276 87592 NCCI

81276 87623 NCCI

81276 87624 NCCI

81276 87625 NCCI

81276 87631 NCCI

81276 87632 NCCI

81276 87633 NCCI

81276 87640 NCCI

81276 87641 NCCI

81276 87650 NCCI

81276 87651 NCCI

81276 87652 NCCI

81276 87653 NCCI

81276 87660 NCCI

81276 87661 NCCI

81276 87797 NCCI

81276 87798 NCCI

81276 87799 NCCI

81276 87800 NCCI

81276 87801 NCCI

81276 88271 NCCI

81276 88272 NCCI

81276 88273 NCCI

81276 88274 NCCI

81276 88275 NCCI

81276 88291 NCCI

81276 88364 NCCI

81276 88365 NCCI

81276 88366 NCCI

81276 88367 NCCI

81276 88368 NCCI

81276 88369 NCCI

81276 88373 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 83 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81276 88374 NCCI

81276 88377 NCCI

81276 G0476 NCCI

81287 80500 NCCI

81287 80502 NCCI

81287 87140 NCCI

81287 87143 NCCI

81287 87147 NCCI

81287 87149 NCCI

81287 87150 NCCI

81287 87152 NCCI

81287 87153 NCCI

81287 87158 NCCI

81287 87470 NCCI

81287 87471 NCCI

81287 87472 NCCI

81287 87475 NCCI

81287 87476 NCCI

81287 87477 NCCI

81287 87480 NCCI

81287 87481 NCCI

81287 87482 NCCI

81287 87483 NCCI

81287 87485 NCCI

81287 87486 NCCI

81287 87487 NCCI

81287 87490 NCCI

81287 87491 NCCI

81287 87492 NCCI

81287 87493 NCCI

81287 87495 NCCI

81287 87496 NCCI

81287 87497 NCCI

81287 87498 NCCI

81287 87500 NCCI

81287 87501 NCCI

81287 87502 NCCI

81287 87503 NCCI

81287 87505 NCCI

81287 87506 NCCI

81287 87507 NCCI

81287 87510 NCCI

81287 87511 NCCI

81287 87512 NCCI

81287 87515 NCCI

81287 87516 NCCI

81287 87517 NCCI

Comprehensive ComponentCode Code Source

81287 87520 NCCI

81287 87521 NCCI

81287 87522 NCCI

81287 87525 NCCI

81287 87526 NCCI

81287 87527 NCCI

81287 87528 NCCI

81287 87529 NCCI

81287 87530 NCCI

81287 87531 NCCI

81287 87532 NCCI

81287 87533 NCCI

81287 87534 NCCI

81287 87535 NCCI

81287 87536 NCCI

81287 87537 NCCI

81287 87538 NCCI

81287 87539 NCCI

81287 87540 NCCI

81287 87541 NCCI

81287 87542 NCCI

81287 87550 NCCI

81287 87551 NCCI

81287 87552 NCCI

81287 87555 NCCI

81287 87556 NCCI

81287 87557 NCCI

81287 87560 NCCI

81287 87561 NCCI

81287 87562 NCCI

81287 87580 NCCI

81287 87581 NCCI

81287 87582 NCCI

81287 87590 NCCI

81287 87591 NCCI

81287 87592 NCCI

81287 87623 NCCI

81287 87624 NCCI

81287 87625 NCCI

81287 87631 NCCI

81287 87632 NCCI

81287 87633 NCCI

81287 87640 NCCI

81287 87641 NCCI

81287 87650 NCCI

81287 87651 NCCI

81287 87652 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 84 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81287 87653 NCCI

81287 87660 NCCI

81287 87661 NCCI

81287 87797 NCCI

81287 87798 NCCI

81287 87799 NCCI

81287 87800 NCCI

81287 87801 NCCI

81287 88271 NCCI

81287 88272 NCCI

81287 88273 NCCI

81287 88274 NCCI

81287 88275 NCCI

81287 88291 NCCI

81287 88364 NCCI

81287 88365 NCCI

81287 88366 NCCI

81287 88367 NCCI

81287 88368 NCCI

81287 88369 NCCI

81287 88373 NCCI

81287 88374 NCCI

81287 88377 NCCI

81287 G0476 NCCI

81288 80500 NCCI

81288 80502 NCCI

81288 81293 NCCI

81288 81294 NCCI

81288 84311 NCCI

81288 87140 NCCI

81288 87143 NCCI

81288 87147 NCCI

81288 87149 NCCI

81288 87150 NCCI

81288 87152 NCCI

81288 87153 NCCI

81288 87158 NCCI

81288 87470 NCCI

81288 87471 NCCI

81288 87472 NCCI

81288 87475 NCCI

81288 87476 NCCI

81288 87477 NCCI

81288 87480 NCCI

81288 87481 NCCI

81288 87482 NCCI

81288 87483 NCCI

Comprehensive ComponentCode Code Source

81288 87485 NCCI

81288 87486 NCCI

81288 87487 NCCI

81288 87490 NCCI

81288 87491 NCCI

81288 87492 NCCI

81288 87493 NCCI

81288 87495 NCCI

81288 87496 NCCI

81288 87497 NCCI

81288 87498 NCCI

81288 87500 NCCI

81288 87501 NCCI

81288 87502 NCCI

81288 87503 NCCI

81288 87505 NCCI

81288 87506 NCCI

81288 87507 NCCI

81288 87510 NCCI

81288 87511 NCCI

81288 87512 NCCI

81288 87515 NCCI

81288 87516 NCCI

81288 87517 NCCI

81288 87520 NCCI

81288 87521 NCCI

81288 87522 NCCI

81288 87525 NCCI

81288 87526 NCCI

81288 87527 NCCI

81288 87528 NCCI

81288 87529 NCCI

81288 87530 NCCI

81288 87531 NCCI

81288 87532 NCCI

81288 87533 NCCI

81288 87534 NCCI

81288 87535 NCCI

81288 87536 NCCI

81288 87537 NCCI

81288 87538 NCCI

81288 87539 NCCI

81288 87540 NCCI

81288 87541 NCCI

81288 87542 NCCI

81288 87550 NCCI

81288 87551 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 85 of 255

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Comprehensive ComponentCode Code Source

81288 87552 NCCI

81288 87555 NCCI

81288 87556 NCCI

81288 87557 NCCI

81288 87560 NCCI

81288 87561 NCCI

81288 87562 NCCI

81288 87580 NCCI

81288 87581 NCCI

81288 87582 NCCI

81288 87590 NCCI

81288 87591 NCCI

81288 87592 NCCI

81288 87623 NCCI

81288 87624 NCCI

81288 87625 NCCI

81288 87631 NCCI

81288 87632 NCCI

81288 87633 NCCI

81288 87640 NCCI

81288 87641 NCCI

81288 87650 NCCI

81288 87651 NCCI

81288 87652 NCCI

81288 87653 NCCI

81288 87660 NCCI

81288 87661 NCCI

81288 87797 NCCI

81288 87798 NCCI

81288 87799 NCCI

81288 87800 NCCI

81288 87801 NCCI

81288 88271 NCCI

81288 88272 NCCI

81288 88273 NCCI

81288 88274 NCCI

81288 88275 NCCI

81288 88291 NCCI

81288 88364 NCCI

81288 88365 NCCI

81288 88366 NCCI

81288 88367 NCCI

81288 88368 NCCI

81288 88369 NCCI

81288 88373 NCCI

81288 88374 NCCI

81288 88377 NCCI

Comprehensive ComponentCode Code Source

81288 G0476 NCCI

81290 80500 NCCI

81290 80502 NCCI

81290 84311 NCCI

81290 87140 NCCI

81290 87143 NCCI

81290 87147 NCCI

81290 87149 NCCI

81290 87150 NCCI

81290 87152 NCCI

81290 87153 NCCI

81290 87158 NCCI

81290 87470 NCCI

81290 87471 NCCI

81290 87472 NCCI

81290 87475 NCCI

81290 87476 NCCI

81290 87477 NCCI

81290 87480 NCCI

81290 87481 NCCI

81290 87482 NCCI

81290 87483 NCCI

81290 87485 NCCI

81290 87486 NCCI

81290 87487 NCCI

81290 87490 NCCI

81290 87491 NCCI

81290 87492 NCCI

81290 87493 NCCI

81290 87495 NCCI

81290 87496 NCCI

81290 87497 NCCI

81290 87498 NCCI

81290 87500 NCCI

81290 87501 NCCI

81290 87502 NCCI

81290 87503 NCCI

81290 87505 NCCI

81290 87506 NCCI

81290 87507 NCCI

81290 87510 NCCI

81290 87511 NCCI

81290 87512 NCCI

81290 87515 NCCI

81290 87516 NCCI

81290 87517 NCCI

81290 87520 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 86 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81290 87521 NCCI

81290 87522 NCCI

81290 87525 NCCI

81290 87526 NCCI

81290 87527 NCCI

81290 87528 NCCI

81290 87529 NCCI

81290 87530 NCCI

81290 87531 NCCI

81290 87532 NCCI

81290 87533 NCCI

81290 87534 NCCI

81290 87535 NCCI

81290 87536 NCCI

81290 87537 NCCI

81290 87538 NCCI

81290 87539 NCCI

81290 87540 NCCI

81290 87541 NCCI

81290 87542 NCCI

81290 87550 NCCI

81290 87551 NCCI

81290 87552 NCCI

81290 87555 NCCI

81290 87556 NCCI

81290 87557 NCCI

81290 87560 NCCI

81290 87561 NCCI

81290 87562 NCCI

81290 87580 NCCI

81290 87581 NCCI

81290 87582 NCCI

81290 87590 NCCI

81290 87591 NCCI

81290 87592 NCCI

81290 87623 NCCI

81290 87624 NCCI

81290 87625 NCCI

81290 87631 NCCI

81290 87632 NCCI

81290 87633 NCCI

81290 87640 NCCI

81290 87641 NCCI

81290 87650 NCCI

81290 87651 NCCI

81290 87652 NCCI

81290 87653 NCCI

Comprehensive ComponentCode Code Source

81290 87660 NCCI

81290 87661 NCCI

81290 87797 NCCI

81290 87798 NCCI

81290 87799 NCCI

81290 87800 NCCI

81290 87801 NCCI

81290 88271 NCCI

81290 88272 NCCI

81290 88273 NCCI

81290 88274 NCCI

81290 88275 NCCI

81290 88291 NCCI

81290 88364 NCCI

81290 88365 NCCI

81290 88366 NCCI

81290 88367 NCCI

81290 88368 NCCI

81290 88369 NCCI

81290 88373 NCCI

81290 88374 NCCI

81290 88377 NCCI

81290 G0476 NCCI

81291 80500 NCCI

81291 80502 NCCI

81291 84311 NCCI

81291 87140 NCCI

81291 87143 NCCI

81291 87147 NCCI

81291 87149 NCCI

81291 87150 NCCI

81291 87152 NCCI

81291 87153 NCCI

81291 87158 NCCI

81291 87470 NCCI

81291 87471 NCCI

81291 87472 NCCI

81291 87475 NCCI

81291 87476 NCCI

81291 87477 NCCI

81291 87480 NCCI

81291 87481 NCCI

81291 87482 NCCI

81291 87483 NCCI

81291 87485 NCCI

81291 87486 NCCI

81291 87487 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 87 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81291 87490 NCCI

81291 87491 NCCI

81291 87492 NCCI

81291 87493 NCCI

81291 87495 NCCI

81291 87496 NCCI

81291 87497 NCCI

81291 87498 NCCI

81291 87500 NCCI

81291 87501 NCCI

81291 87502 NCCI

81291 87503 NCCI

81291 87505 NCCI

81291 87506 NCCI

81291 87507 NCCI

81291 87510 NCCI

81291 87511 NCCI

81291 87512 NCCI

81291 87515 NCCI

81291 87516 NCCI

81291 87517 NCCI

81291 87520 NCCI

81291 87521 NCCI

81291 87522 NCCI

81291 87525 NCCI

81291 87526 NCCI

81291 87527 NCCI

81291 87528 NCCI

81291 87529 NCCI

81291 87530 NCCI

81291 87531 NCCI

81291 87532 NCCI

81291 87533 NCCI

81291 87534 NCCI

81291 87535 NCCI

81291 87536 NCCI

81291 87537 NCCI

81291 87538 NCCI

81291 87539 NCCI

81291 87540 NCCI

81291 87541 NCCI

81291 87542 NCCI

81291 87550 NCCI

81291 87551 NCCI

81291 87552 NCCI

81291 87555 NCCI

81291 87556 NCCI

Comprehensive ComponentCode Code Source

81291 87557 NCCI

81291 87560 NCCI

81291 87561 NCCI

81291 87562 NCCI

81291 87580 NCCI

81291 87581 NCCI

81291 87582 NCCI

81291 87590 NCCI

81291 87591 NCCI

81291 87592 NCCI

81291 87623 NCCI

81291 87624 NCCI

81291 87625 NCCI

81291 87631 NCCI

81291 87632 NCCI

81291 87633 NCCI

81291 87640 NCCI

81291 87641 NCCI

81291 87650 NCCI

81291 87651 NCCI

81291 87652 NCCI

81291 87653 NCCI

81291 87660 NCCI

81291 87661 NCCI

81291 87797 NCCI

81291 87798 NCCI

81291 87799 NCCI

81291 87800 NCCI

81291 87801 NCCI

81291 88271 NCCI

81291 88272 NCCI

81291 88273 NCCI

81291 88274 NCCI

81291 88275 NCCI

81291 88291 NCCI

81291 88364 NCCI

81291 88365 NCCI

81291 88366 NCCI

81291 88367 NCCI

81291 88368 NCCI

81291 88369 NCCI

81291 88373 NCCI

81291 88374 NCCI

81291 88377 NCCI

81291 G0476 NCCI

81292 80500 NCCI

81292 80502 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 88 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81292 81293 NCCI

81292 81294 NCCI

81292 84311 NCCI

81292 87140 NCCI

81292 87143 NCCI

81292 87147 NCCI

81292 87149 NCCI

81292 87150 NCCI

81292 87152 NCCI

81292 87153 NCCI

81292 87158 NCCI

81292 87470 NCCI

81292 87471 NCCI

81292 87472 NCCI

81292 87475 NCCI

81292 87476 NCCI

81292 87477 NCCI

81292 87480 NCCI

81292 87481 NCCI

81292 87482 NCCI

81292 87483 NCCI

81292 87485 NCCI

81292 87486 NCCI

81292 87487 NCCI

81292 87490 NCCI

81292 87491 NCCI

81292 87492 NCCI

81292 87493 NCCI

81292 87495 NCCI

81292 87496 NCCI

81292 87497 NCCI

81292 87498 NCCI

81292 87500 NCCI

81292 87501 NCCI

81292 87502 NCCI

81292 87503 NCCI

81292 87505 NCCI

81292 87506 NCCI

81292 87507 NCCI

81292 87510 NCCI

81292 87511 NCCI

81292 87512 NCCI

81292 87515 NCCI

81292 87516 NCCI

81292 87517 NCCI

81292 87520 NCCI

81292 87521 NCCI

Comprehensive ComponentCode Code Source

81292 87522 NCCI

81292 87525 NCCI

81292 87526 NCCI

81292 87527 NCCI

81292 87528 NCCI

81292 87529 NCCI

81292 87530 NCCI

81292 87531 NCCI

81292 87532 NCCI

81292 87533 NCCI

81292 87534 NCCI

81292 87535 NCCI

81292 87536 NCCI

81292 87537 NCCI

81292 87538 NCCI

81292 87539 NCCI

81292 87540 NCCI

81292 87541 NCCI

81292 87542 NCCI

81292 87550 NCCI

81292 87551 NCCI

81292 87552 NCCI

81292 87555 NCCI

81292 87556 NCCI

81292 87557 NCCI

81292 87560 NCCI

81292 87561 NCCI

81292 87562 NCCI

81292 87580 NCCI

81292 87581 NCCI

81292 87582 NCCI

81292 87590 NCCI

81292 87591 NCCI

81292 87592 NCCI

81292 87623 NCCI

81292 87624 NCCI

81292 87625 NCCI

81292 87631 NCCI

81292 87632 NCCI

81292 87633 NCCI

81292 87640 NCCI

81292 87641 NCCI

81292 87650 NCCI

81292 87651 NCCI

81292 87652 NCCI

81292 87653 NCCI

81292 87660 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 89 of 255

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Comprehensive ComponentCode Code Source

81292 87661 NCCI

81292 87797 NCCI

81292 87798 NCCI

81292 87799 NCCI

81292 87800 NCCI

81292 87801 NCCI

81292 88271 NCCI

81292 88272 NCCI

81292 88273 NCCI

81292 88274 NCCI

81292 88275 NCCI

81292 88291 NCCI

81292 88364 NCCI

81292 88365 NCCI

81292 88366 NCCI

81292 88367 NCCI

81292 88368 NCCI

81292 88369 NCCI

81292 88373 NCCI

81292 88374 NCCI

81292 88377 NCCI

81292 G0476 NCCI

81293 80500 NCCI

81293 80502 NCCI

81293 81294 NCCI

81293 84311 NCCI

81293 87140 NCCI

81293 87143 NCCI

81293 87147 NCCI

81293 87149 NCCI

81293 87150 NCCI

81293 87152 NCCI

81293 87153 NCCI

81293 87158 NCCI

81293 87470 NCCI

81293 87471 NCCI

81293 87472 NCCI

81293 87475 NCCI

81293 87476 NCCI

81293 87477 NCCI

81293 87480 NCCI

81293 87481 NCCI

81293 87482 NCCI

81293 87483 NCCI

81293 87485 NCCI

81293 87486 NCCI

81293 87487 NCCI

Comprehensive ComponentCode Code Source

81293 87490 NCCI

81293 87491 NCCI

81293 87492 NCCI

81293 87493 NCCI

81293 87495 NCCI

81293 87496 NCCI

81293 87497 NCCI

81293 87498 NCCI

81293 87500 NCCI

81293 87501 NCCI

81293 87502 NCCI

81293 87503 NCCI

81293 87505 NCCI

81293 87506 NCCI

81293 87507 NCCI

81293 87510 NCCI

81293 87511 NCCI

81293 87512 NCCI

81293 87515 NCCI

81293 87516 NCCI

81293 87517 NCCI

81293 87520 NCCI

81293 87521 NCCI

81293 87522 NCCI

81293 87525 NCCI

81293 87526 NCCI

81293 87527 NCCI

81293 87528 NCCI

81293 87529 NCCI

81293 87530 NCCI

81293 87531 NCCI

81293 87532 NCCI

81293 87533 NCCI

81293 87534 NCCI

81293 87535 NCCI

81293 87536 NCCI

81293 87537 NCCI

81293 87538 NCCI

81293 87539 NCCI

81293 87540 NCCI

81293 87541 NCCI

81293 87542 NCCI

81293 87550 NCCI

81293 87551 NCCI

81293 87552 NCCI

81293 87555 NCCI

81293 87556 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 90 of 255

Page 91: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81293 87557 NCCI

81293 87560 NCCI

81293 87561 NCCI

81293 87562 NCCI

81293 87580 NCCI

81293 87581 NCCI

81293 87582 NCCI

81293 87590 NCCI

81293 87591 NCCI

81293 87592 NCCI

81293 87623 NCCI

81293 87624 NCCI

81293 87625 NCCI

81293 87631 NCCI

81293 87632 NCCI

81293 87633 NCCI

81293 87640 NCCI

81293 87641 NCCI

81293 87650 NCCI

81293 87651 NCCI

81293 87652 NCCI

81293 87653 NCCI

81293 87660 NCCI

81293 87661 NCCI

81293 87797 NCCI

81293 87798 NCCI

81293 87799 NCCI

81293 87800 NCCI

81293 87801 NCCI

81293 88271 NCCI

81293 88272 NCCI

81293 88273 NCCI

81293 88274 NCCI

81293 88275 NCCI

81293 88291 NCCI

81293 88364 NCCI

81293 88365 NCCI

81293 88366 NCCI

81293 88367 NCCI

81293 88368 NCCI

81293 88369 NCCI

81293 88373 NCCI

81293 88374 NCCI

81293 88377 NCCI

81293 G0476 NCCI

81294 80500 NCCI

81294 80502 NCCI

Comprehensive ComponentCode Code Source

81294 84311 NCCI

81294 87140 NCCI

81294 87143 NCCI

81294 87147 NCCI

81294 87149 NCCI

81294 87150 NCCI

81294 87152 NCCI

81294 87153 NCCI

81294 87158 NCCI

81294 87470 NCCI

81294 87471 NCCI

81294 87472 NCCI

81294 87475 NCCI

81294 87476 NCCI

81294 87477 NCCI

81294 87480 NCCI

81294 87481 NCCI

81294 87482 NCCI

81294 87483 NCCI

81294 87485 NCCI

81294 87486 NCCI

81294 87487 NCCI

81294 87490 NCCI

81294 87491 NCCI

81294 87492 NCCI

81294 87493 NCCI

81294 87495 NCCI

81294 87496 NCCI

81294 87497 NCCI

81294 87498 NCCI

81294 87500 NCCI

81294 87501 NCCI

81294 87502 NCCI

81294 87503 NCCI

81294 87505 NCCI

81294 87506 NCCI

81294 87507 NCCI

81294 87510 NCCI

81294 87511 NCCI

81294 87512 NCCI

81294 87515 NCCI

81294 87516 NCCI

81294 87517 NCCI

81294 87520 NCCI

81294 87521 NCCI

81294 87522 NCCI

81294 87525 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 91 of 255

Page 92: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81294 87526 NCCI

81294 87527 NCCI

81294 87528 NCCI

81294 87529 NCCI

81294 87530 NCCI

81294 87531 NCCI

81294 87532 NCCI

81294 87533 NCCI

81294 87534 NCCI

81294 87535 NCCI

81294 87536 NCCI

81294 87537 NCCI

81294 87538 NCCI

81294 87539 NCCI

81294 87540 NCCI

81294 87541 NCCI

81294 87542 NCCI

81294 87550 NCCI

81294 87551 NCCI

81294 87552 NCCI

81294 87555 NCCI

81294 87556 NCCI

81294 87557 NCCI

81294 87560 NCCI

81294 87561 NCCI

81294 87562 NCCI

81294 87580 NCCI

81294 87581 NCCI

81294 87582 NCCI

81294 87590 NCCI

81294 87591 NCCI

81294 87592 NCCI

81294 87623 NCCI

81294 87624 NCCI

81294 87625 NCCI

81294 87631 NCCI

81294 87632 NCCI

81294 87633 NCCI

81294 87640 NCCI

81294 87641 NCCI

81294 87650 NCCI

81294 87651 NCCI

81294 87652 NCCI

81294 87653 NCCI

81294 87660 NCCI

81294 87661 NCCI

81294 87797 NCCI

Comprehensive ComponentCode Code Source

81294 87798 NCCI

81294 87799 NCCI

81294 87800 NCCI

81294 87801 NCCI

81294 88271 NCCI

81294 88272 NCCI

81294 88273 NCCI

81294 88274 NCCI

81294 88275 NCCI

81294 88291 NCCI

81294 88364 NCCI

81294 88365 NCCI

81294 88366 NCCI

81294 88367 NCCI

81294 88368 NCCI

81294 88369 NCCI

81294 88373 NCCI

81294 88374 NCCI

81294 88377 NCCI

81294 G0476 NCCI

81295 80500 NCCI

81295 80502 NCCI

81295 81296 NCCI

81295 81297 NCCI

81295 84311 NCCI

81295 87140 NCCI

81295 87143 NCCI

81295 87147 NCCI

81295 87149 NCCI

81295 87150 NCCI

81295 87152 NCCI

81295 87153 NCCI

81295 87158 NCCI

81295 87470 NCCI

81295 87471 NCCI

81295 87472 NCCI

81295 87475 NCCI

81295 87476 NCCI

81295 87477 NCCI

81295 87480 NCCI

81295 87481 NCCI

81295 87482 NCCI

81295 87483 NCCI

81295 87485 NCCI

81295 87486 NCCI

81295 87487 NCCI

81295 87490 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 92 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81295 87491 NCCI

81295 87492 NCCI

81295 87493 NCCI

81295 87495 NCCI

81295 87496 NCCI

81295 87497 NCCI

81295 87498 NCCI

81295 87500 NCCI

81295 87501 NCCI

81295 87502 NCCI

81295 87503 NCCI

81295 87505 NCCI

81295 87506 NCCI

81295 87507 NCCI

81295 87510 NCCI

81295 87511 NCCI

81295 87512 NCCI

81295 87515 NCCI

81295 87516 NCCI

81295 87517 NCCI

81295 87520 NCCI

81295 87521 NCCI

81295 87522 NCCI

81295 87525 NCCI

81295 87526 NCCI

81295 87527 NCCI

81295 87528 NCCI

81295 87529 NCCI

81295 87530 NCCI

81295 87531 NCCI

81295 87532 NCCI

81295 87533 NCCI

81295 87534 NCCI

81295 87535 NCCI

81295 87536 NCCI

81295 87537 NCCI

81295 87538 NCCI

81295 87539 NCCI

81295 87540 NCCI

81295 87541 NCCI

81295 87542 NCCI

81295 87550 NCCI

81295 87551 NCCI

81295 87552 NCCI

81295 87555 NCCI

81295 87556 NCCI

81295 87557 NCCI

Comprehensive ComponentCode Code Source

81295 87560 NCCI

81295 87561 NCCI

81295 87562 NCCI

81295 87580 NCCI

81295 87581 NCCI

81295 87582 NCCI

81295 87590 NCCI

81295 87591 NCCI

81295 87592 NCCI

81295 87623 NCCI

81295 87624 NCCI

81295 87625 NCCI

81295 87631 NCCI

81295 87632 NCCI

81295 87633 NCCI

81295 87640 NCCI

81295 87641 NCCI

81295 87650 NCCI

81295 87651 NCCI

81295 87652 NCCI

81295 87653 NCCI

81295 87660 NCCI

81295 87661 NCCI

81295 87797 NCCI

81295 87798 NCCI

81295 87799 NCCI

81295 87800 NCCI

81295 87801 NCCI

81295 88271 NCCI

81295 88272 NCCI

81295 88273 NCCI

81295 88274 NCCI

81295 88275 NCCI

81295 88291 NCCI

81295 88364 NCCI

81295 88365 NCCI

81295 88366 NCCI

81295 88367 NCCI

81295 88368 NCCI

81295 88369 NCCI

81295 88373 NCCI

81295 88374 NCCI

81295 88377 NCCI

81295 G0476 NCCI

81296 80500 NCCI

81296 80502 NCCI

81296 81297 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 93 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81296 84311 NCCI

81296 87140 NCCI

81296 87143 NCCI

81296 87147 NCCI

81296 87149 NCCI

81296 87150 NCCI

81296 87152 NCCI

81296 87153 NCCI

81296 87158 NCCI

81296 87470 NCCI

81296 87471 NCCI

81296 87472 NCCI

81296 87475 NCCI

81296 87476 NCCI

81296 87477 NCCI

81296 87480 NCCI

81296 87481 NCCI

81296 87482 NCCI

81296 87483 NCCI

81296 87485 NCCI

81296 87486 NCCI

81296 87487 NCCI

81296 87490 NCCI

81296 87491 NCCI

81296 87492 NCCI

81296 87493 NCCI

81296 87495 NCCI

81296 87496 NCCI

81296 87497 NCCI

81296 87498 NCCI

81296 87500 NCCI

81296 87501 NCCI

81296 87502 NCCI

81296 87503 NCCI

81296 87505 NCCI

81296 87506 NCCI

81296 87507 NCCI

81296 87510 NCCI

81296 87511 NCCI

81296 87512 NCCI

81296 87515 NCCI

81296 87516 NCCI

81296 87517 NCCI

81296 87520 NCCI

81296 87521 NCCI

81296 87522 NCCI

81296 87525 NCCI

Comprehensive ComponentCode Code Source

81296 87526 NCCI

81296 87527 NCCI

81296 87528 NCCI

81296 87529 NCCI

81296 87530 NCCI

81296 87531 NCCI

81296 87532 NCCI

81296 87533 NCCI

81296 87534 NCCI

81296 87535 NCCI

81296 87536 NCCI

81296 87537 NCCI

81296 87538 NCCI

81296 87539 NCCI

81296 87540 NCCI

81296 87541 NCCI

81296 87542 NCCI

81296 87550 NCCI

81296 87551 NCCI

81296 87552 NCCI

81296 87555 NCCI

81296 87556 NCCI

81296 87557 NCCI

81296 87560 NCCI

81296 87561 NCCI

81296 87562 NCCI

81296 87580 NCCI

81296 87581 NCCI

81296 87582 NCCI

81296 87590 NCCI

81296 87591 NCCI

81296 87592 NCCI

81296 87623 NCCI

81296 87624 NCCI

81296 87625 NCCI

81296 87631 NCCI

81296 87632 NCCI

81296 87633 NCCI

81296 87640 NCCI

81296 87641 NCCI

81296 87650 NCCI

81296 87651 NCCI

81296 87652 NCCI

81296 87653 NCCI

81296 87660 NCCI

81296 87661 NCCI

81296 87797 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 94 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81296 87798 NCCI

81296 87799 NCCI

81296 87800 NCCI

81296 87801 NCCI

81296 88271 NCCI

81296 88272 NCCI

81296 88273 NCCI

81296 88274 NCCI

81296 88275 NCCI

81296 88291 NCCI

81296 88364 NCCI

81296 88365 NCCI

81296 88366 NCCI

81296 88367 NCCI

81296 88368 NCCI

81296 88369 NCCI

81296 88373 NCCI

81296 88374 NCCI

81296 88377 NCCI

81296 G0476 NCCI

81297 80500 NCCI

81297 80502 NCCI

81297 84311 NCCI

81297 87140 NCCI

81297 87143 NCCI

81297 87147 NCCI

81297 87149 NCCI

81297 87150 NCCI

81297 87152 NCCI

81297 87153 NCCI

81297 87158 NCCI

81297 87470 NCCI

81297 87471 NCCI

81297 87472 NCCI

81297 87475 NCCI

81297 87476 NCCI

81297 87477 NCCI

81297 87480 NCCI

81297 87481 NCCI

81297 87482 NCCI

81297 87483 NCCI

81297 87485 NCCI

81297 87486 NCCI

81297 87487 NCCI

81297 87490 NCCI

81297 87491 NCCI

81297 87492 NCCI

Comprehensive ComponentCode Code Source

81297 87493 NCCI

81297 87495 NCCI

81297 87496 NCCI

81297 87497 NCCI

81297 87498 NCCI

81297 87500 NCCI

81297 87501 NCCI

81297 87502 NCCI

81297 87503 NCCI

81297 87505 NCCI

81297 87506 NCCI

81297 87507 NCCI

81297 87510 NCCI

81297 87511 NCCI

81297 87512 NCCI

81297 87515 NCCI

81297 87516 NCCI

81297 87517 NCCI

81297 87520 NCCI

81297 87521 NCCI

81297 87522 NCCI

81297 87525 NCCI

81297 87526 NCCI

81297 87527 NCCI

81297 87528 NCCI

81297 87529 NCCI

81297 87530 NCCI

81297 87531 NCCI

81297 87532 NCCI

81297 87533 NCCI

81297 87534 NCCI

81297 87535 NCCI

81297 87536 NCCI

81297 87537 NCCI

81297 87538 NCCI

81297 87539 NCCI

81297 87540 NCCI

81297 87541 NCCI

81297 87542 NCCI

81297 87550 NCCI

81297 87551 NCCI

81297 87552 NCCI

81297 87555 NCCI

81297 87556 NCCI

81297 87557 NCCI

81297 87560 NCCI

81297 87561 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 95 of 255

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Comprehensive ComponentCode Code Source

81297 87562 NCCI

81297 87580 NCCI

81297 87581 NCCI

81297 87582 NCCI

81297 87590 NCCI

81297 87591 NCCI

81297 87592 NCCI

81297 87623 NCCI

81297 87624 NCCI

81297 87625 NCCI

81297 87631 NCCI

81297 87632 NCCI

81297 87633 NCCI

81297 87640 NCCI

81297 87641 NCCI

81297 87650 NCCI

81297 87651 NCCI

81297 87652 NCCI

81297 87653 NCCI

81297 87660 NCCI

81297 87661 NCCI

81297 87797 NCCI

81297 87798 NCCI

81297 87799 NCCI

81297 87800 NCCI

81297 87801 NCCI

81297 88271 NCCI

81297 88272 NCCI

81297 88273 NCCI

81297 88274 NCCI

81297 88275 NCCI

81297 88291 NCCI

81297 88364 NCCI

81297 88365 NCCI

81297 88366 NCCI

81297 88367 NCCI

81297 88368 NCCI

81297 88369 NCCI

81297 88373 NCCI

81297 88374 NCCI

81297 88377 NCCI

81297 G0476 NCCI

81298 80500 NCCI

81298 80502 NCCI

81298 81299 NCCI

81298 81300 NCCI

81298 84311 NCCI

Comprehensive ComponentCode Code Source

81298 87140 NCCI

81298 87143 NCCI

81298 87147 NCCI

81298 87149 NCCI

81298 87150 NCCI

81298 87152 NCCI

81298 87153 NCCI

81298 87158 NCCI

81298 87470 NCCI

81298 87471 NCCI

81298 87472 NCCI

81298 87475 NCCI

81298 87476 NCCI

81298 87477 NCCI

81298 87480 NCCI

81298 87481 NCCI

81298 87482 NCCI

81298 87483 NCCI

81298 87485 NCCI

81298 87486 NCCI

81298 87487 NCCI

81298 87490 NCCI

81298 87491 NCCI

81298 87492 NCCI

81298 87493 NCCI

81298 87495 NCCI

81298 87496 NCCI

81298 87497 NCCI

81298 87498 NCCI

81298 87500 NCCI

81298 87501 NCCI

81298 87502 NCCI

81298 87503 NCCI

81298 87505 NCCI

81298 87506 NCCI

81298 87507 NCCI

81298 87510 NCCI

81298 87511 NCCI

81298 87512 NCCI

81298 87515 NCCI

81298 87516 NCCI

81298 87517 NCCI

81298 87520 NCCI

81298 87521 NCCI

81298 87522 NCCI

81298 87525 NCCI

81298 87526 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 96 of 255

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Comprehensive ComponentCode Code Source

81298 87527 NCCI

81298 87528 NCCI

81298 87529 NCCI

81298 87530 NCCI

81298 87531 NCCI

81298 87532 NCCI

81298 87533 NCCI

81298 87534 NCCI

81298 87535 NCCI

81298 87536 NCCI

81298 87537 NCCI

81298 87538 NCCI

81298 87539 NCCI

81298 87540 NCCI

81298 87541 NCCI

81298 87542 NCCI

81298 87550 NCCI

81298 87551 NCCI

81298 87552 NCCI

81298 87555 NCCI

81298 87556 NCCI

81298 87557 NCCI

81298 87560 NCCI

81298 87561 NCCI

81298 87562 NCCI

81298 87580 NCCI

81298 87581 NCCI

81298 87582 NCCI

81298 87590 NCCI

81298 87591 NCCI

81298 87592 NCCI

81298 87623 NCCI

81298 87624 NCCI

81298 87625 NCCI

81298 87631 NCCI

81298 87632 NCCI

81298 87633 NCCI

81298 87640 NCCI

81298 87641 NCCI

81298 87650 NCCI

81298 87651 NCCI

81298 87652 NCCI

81298 87653 NCCI

81298 87660 NCCI

81298 87661 NCCI

81298 87797 NCCI

81298 87798 NCCI

Comprehensive ComponentCode Code Source

81298 87799 NCCI

81298 87800 NCCI

81298 87801 NCCI

81298 88271 NCCI

81298 88272 NCCI

81298 88273 NCCI

81298 88274 NCCI

81298 88275 NCCI

81298 88291 NCCI

81298 88364 NCCI

81298 88365 NCCI

81298 88366 NCCI

81298 88367 NCCI

81298 88368 NCCI

81298 88369 NCCI

81298 88373 NCCI

81298 88374 NCCI

81298 88377 NCCI

81298 G0476 NCCI

81299 80500 NCCI

81299 80502 NCCI

81299 81300 NCCI

81299 84311 NCCI

81299 87140 NCCI

81299 87143 NCCI

81299 87147 NCCI

81299 87149 NCCI

81299 87150 NCCI

81299 87152 NCCI

81299 87153 NCCI

81299 87158 NCCI

81299 87470 NCCI

81299 87471 NCCI

81299 87472 NCCI

81299 87475 NCCI

81299 87476 NCCI

81299 87477 NCCI

81299 87480 NCCI

81299 87481 NCCI

81299 87482 NCCI

81299 87483 NCCI

81299 87485 NCCI

81299 87486 NCCI

81299 87487 NCCI

81299 87490 NCCI

81299 87491 NCCI

81299 87492 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 97 of 255

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Comprehensive ComponentCode Code Source

81299 87493 NCCI

81299 87495 NCCI

81299 87496 NCCI

81299 87497 NCCI

81299 87498 NCCI

81299 87500 NCCI

81299 87501 NCCI

81299 87502 NCCI

81299 87503 NCCI

81299 87505 NCCI

81299 87506 NCCI

81299 87507 NCCI

81299 87510 NCCI

81299 87511 NCCI

81299 87512 NCCI

81299 87515 NCCI

81299 87516 NCCI

81299 87517 NCCI

81299 87520 NCCI

81299 87521 NCCI

81299 87522 NCCI

81299 87525 NCCI

81299 87526 NCCI

81299 87527 NCCI

81299 87528 NCCI

81299 87529 NCCI

81299 87530 NCCI

81299 87531 NCCI

81299 87532 NCCI

81299 87533 NCCI

81299 87534 NCCI

81299 87535 NCCI

81299 87536 NCCI

81299 87537 NCCI

81299 87538 NCCI

81299 87539 NCCI

81299 87540 NCCI

81299 87541 NCCI

81299 87542 NCCI

81299 87550 NCCI

81299 87551 NCCI

81299 87552 NCCI

81299 87555 NCCI

81299 87556 NCCI

81299 87557 NCCI

81299 87560 NCCI

81299 87561 NCCI

Comprehensive ComponentCode Code Source

81299 87562 NCCI

81299 87580 NCCI

81299 87581 NCCI

81299 87582 NCCI

81299 87590 NCCI

81299 87591 NCCI

81299 87592 NCCI

81299 87623 NCCI

81299 87624 NCCI

81299 87625 NCCI

81299 87631 NCCI

81299 87632 NCCI

81299 87633 NCCI

81299 87640 NCCI

81299 87641 NCCI

81299 87650 NCCI

81299 87651 NCCI

81299 87652 NCCI

81299 87653 NCCI

81299 87660 NCCI

81299 87661 NCCI

81299 87797 NCCI

81299 87798 NCCI

81299 87799 NCCI

81299 87800 NCCI

81299 87801 NCCI

81299 88271 NCCI

81299 88272 NCCI

81299 88273 NCCI

81299 88274 NCCI

81299 88275 NCCI

81299 88291 NCCI

81299 88364 NCCI

81299 88365 NCCI

81299 88366 NCCI

81299 88367 NCCI

81299 88368 NCCI

81299 88369 NCCI

81299 88373 NCCI

81299 88374 NCCI

81299 88377 NCCI

81299 G0476 NCCI

81300 80500 NCCI

81300 80502 NCCI

81300 84311 NCCI

81300 87140 NCCI

81300 87143 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 98 of 255

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Effective Date of Service: 7/1/2017

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Comprehensive ComponentCode Code Source

81300 87147 NCCI

81300 87149 NCCI

81300 87150 NCCI

81300 87152 NCCI

81300 87153 NCCI

81300 87158 NCCI

81300 87470 NCCI

81300 87471 NCCI

81300 87472 NCCI

81300 87475 NCCI

81300 87476 NCCI

81300 87477 NCCI

81300 87480 NCCI

81300 87481 NCCI

81300 87482 NCCI

81300 87483 NCCI

81300 87485 NCCI

81300 87486 NCCI

81300 87487 NCCI

81300 87490 NCCI

81300 87491 NCCI

81300 87492 NCCI

81300 87493 NCCI

81300 87495 NCCI

81300 87496 NCCI

81300 87497 NCCI

81300 87498 NCCI

81300 87500 NCCI

81300 87501 NCCI

81300 87502 NCCI

81300 87503 NCCI

81300 87505 NCCI

81300 87506 NCCI

81300 87507 NCCI

81300 87510 NCCI

81300 87511 NCCI

81300 87512 NCCI

81300 87515 NCCI

81300 87516 NCCI

81300 87517 NCCI

81300 87520 NCCI

81300 87521 NCCI

81300 87522 NCCI

81300 87525 NCCI

81300 87526 NCCI

81300 87527 NCCI

81300 87528 NCCI

Comprehensive ComponentCode Code Source

81300 87529 NCCI

81300 87530 NCCI

81300 87531 NCCI

81300 87532 NCCI

81300 87533 NCCI

81300 87534 NCCI

81300 87535 NCCI

81300 87536 NCCI

81300 87537 NCCI

81300 87538 NCCI

81300 87539 NCCI

81300 87540 NCCI

81300 87541 NCCI

81300 87542 NCCI

81300 87550 NCCI

81300 87551 NCCI

81300 87552 NCCI

81300 87555 NCCI

81300 87556 NCCI

81300 87557 NCCI

81300 87560 NCCI

81300 87561 NCCI

81300 87562 NCCI

81300 87580 NCCI

81300 87581 NCCI

81300 87582 NCCI

81300 87590 NCCI

81300 87591 NCCI

81300 87592 NCCI

81300 87623 NCCI

81300 87624 NCCI

81300 87625 NCCI

81300 87631 NCCI

81300 87632 NCCI

81300 87633 NCCI

81300 87640 NCCI

81300 87641 NCCI

81300 87650 NCCI

81300 87651 NCCI

81300 87652 NCCI

81300 87653 NCCI

81300 87660 NCCI

81300 87661 NCCI

81300 87797 NCCI

81300 87798 NCCI

81300 87799 NCCI

81300 87800 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 99 of 255

Page 100: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81300 87801 NCCI

81300 88271 NCCI

81300 88272 NCCI

81300 88273 NCCI

81300 88274 NCCI

81300 88275 NCCI

81300 88291 NCCI

81300 88364 NCCI

81300 88365 NCCI

81300 88366 NCCI

81300 88367 NCCI

81300 88368 NCCI

81300 88369 NCCI

81300 88373 NCCI

81300 88374 NCCI

81300 88377 NCCI

81300 G0476 NCCI

81301 80500 NCCI

81301 80502 NCCI

81301 84311 NCCI

81301 87140 NCCI

81301 87143 NCCI

81301 87147 NCCI

81301 87149 NCCI

81301 87150 NCCI

81301 87152 NCCI

81301 87153 NCCI

81301 87158 NCCI

81301 87470 NCCI

81301 87471 NCCI

81301 87472 NCCI

81301 87475 NCCI

81301 87476 NCCI

81301 87477 NCCI

81301 87480 NCCI

81301 87481 NCCI

81301 87482 NCCI

81301 87483 NCCI

81301 87485 NCCI

81301 87486 NCCI

81301 87487 NCCI

81301 87490 NCCI

81301 87491 NCCI

81301 87492 NCCI

81301 87493 NCCI

81301 87495 NCCI

81301 87496 NCCI

Comprehensive ComponentCode Code Source

81301 87497 NCCI

81301 87498 NCCI

81301 87500 NCCI

81301 87501 NCCI

81301 87502 NCCI

81301 87503 NCCI

81301 87505 NCCI

81301 87506 NCCI

81301 87507 NCCI

81301 87510 NCCI

81301 87511 NCCI

81301 87512 NCCI

81301 87515 NCCI

81301 87516 NCCI

81301 87517 NCCI

81301 87520 NCCI

81301 87521 NCCI

81301 87522 NCCI

81301 87525 NCCI

81301 87526 NCCI

81301 87527 NCCI

81301 87528 NCCI

81301 87529 NCCI

81301 87530 NCCI

81301 87531 NCCI

81301 87532 NCCI

81301 87533 NCCI

81301 87534 NCCI

81301 87535 NCCI

81301 87536 NCCI

81301 87537 NCCI

81301 87538 NCCI

81301 87539 NCCI

81301 87540 NCCI

81301 87541 NCCI

81301 87542 NCCI

81301 87550 NCCI

81301 87551 NCCI

81301 87552 NCCI

81301 87555 NCCI

81301 87556 NCCI

81301 87557 NCCI

81301 87560 NCCI

81301 87561 NCCI

81301 87562 NCCI

81301 87580 NCCI

81301 87581 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 100 of 255

Page 101: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81301 87582 NCCI

81301 87590 NCCI

81301 87591 NCCI

81301 87592 NCCI

81301 87623 NCCI

81301 87624 NCCI

81301 87625 NCCI

81301 87631 NCCI

81301 87632 NCCI

81301 87633 NCCI

81301 87640 NCCI

81301 87641 NCCI

81301 87650 NCCI

81301 87651 NCCI

81301 87652 NCCI

81301 87653 NCCI

81301 87660 NCCI

81301 87661 NCCI

81301 87797 NCCI

81301 87798 NCCI

81301 87799 NCCI

81301 87800 NCCI

81301 87801 NCCI

81301 88271 NCCI

81301 88272 NCCI

81301 88273 NCCI

81301 88274 NCCI

81301 88275 NCCI

81301 88291 NCCI

81301 88364 NCCI

81301 88365 NCCI

81301 88366 NCCI

81301 88367 NCCI

81301 88368 NCCI

81301 88369 NCCI

81301 88373 NCCI

81301 88374 NCCI

81301 88377 NCCI

81301 G0476 NCCI

81302 80500 NCCI

81302 80502 NCCI

81302 81303 NCCI

81302 81304 NCCI

81302 84311 NCCI

81302 87140 NCCI

81302 87143 NCCI

81302 87147 NCCI

Comprehensive ComponentCode Code Source

81302 87149 NCCI

81302 87150 NCCI

81302 87152 NCCI

81302 87153 NCCI

81302 87158 NCCI

81302 87470 NCCI

81302 87471 NCCI

81302 87472 NCCI

81302 87475 NCCI

81302 87476 NCCI

81302 87477 NCCI

81302 87480 NCCI

81302 87481 NCCI

81302 87482 NCCI

81302 87483 NCCI

81302 87485 NCCI

81302 87486 NCCI

81302 87487 NCCI

81302 87490 NCCI

81302 87491 NCCI

81302 87492 NCCI

81302 87493 NCCI

81302 87495 NCCI

81302 87496 NCCI

81302 87497 NCCI

81302 87498 NCCI

81302 87500 NCCI

81302 87501 NCCI

81302 87502 NCCI

81302 87503 NCCI

81302 87505 NCCI

81302 87506 NCCI

81302 87507 NCCI

81302 87510 NCCI

81302 87511 NCCI

81302 87512 NCCI

81302 87515 NCCI

81302 87516 NCCI

81302 87517 NCCI

81302 87520 NCCI

81302 87521 NCCI

81302 87522 NCCI

81302 87525 NCCI

81302 87526 NCCI

81302 87527 NCCI

81302 87528 NCCI

81302 87529 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 101 of 255

Page 102: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81302 87530 NCCI

81302 87531 NCCI

81302 87532 NCCI

81302 87533 NCCI

81302 87534 NCCI

81302 87535 NCCI

81302 87536 NCCI

81302 87537 NCCI

81302 87538 NCCI

81302 87539 NCCI

81302 87540 NCCI

81302 87541 NCCI

81302 87542 NCCI

81302 87550 NCCI

81302 87551 NCCI

81302 87552 NCCI

81302 87555 NCCI

81302 87556 NCCI

81302 87557 NCCI

81302 87560 NCCI

81302 87561 NCCI

81302 87562 NCCI

81302 87580 NCCI

81302 87581 NCCI

81302 87582 NCCI

81302 87590 NCCI

81302 87591 NCCI

81302 87592 NCCI

81302 87623 NCCI

81302 87624 NCCI

81302 87625 NCCI

81302 87631 NCCI

81302 87632 NCCI

81302 87633 NCCI

81302 87640 NCCI

81302 87641 NCCI

81302 87650 NCCI

81302 87651 NCCI

81302 87652 NCCI

81302 87653 NCCI

81302 87660 NCCI

81302 87661 NCCI

81302 87797 NCCI

81302 87798 NCCI

81302 87799 NCCI

81302 87800 NCCI

81302 87801 NCCI

Comprehensive ComponentCode Code Source

81302 88271 NCCI

81302 88272 NCCI

81302 88273 NCCI

81302 88274 NCCI

81302 88275 NCCI

81302 88291 NCCI

81302 88364 NCCI

81302 88365 NCCI

81302 88366 NCCI

81302 88367 NCCI

81302 88368 NCCI

81302 88369 NCCI

81302 88373 NCCI

81302 88374 NCCI

81302 88377 NCCI

81302 G0476 NCCI

81303 80500 NCCI

81303 80502 NCCI

81303 81304 NCCI

81303 84311 NCCI

81303 87140 NCCI

81303 87143 NCCI

81303 87147 NCCI

81303 87149 NCCI

81303 87150 NCCI

81303 87152 NCCI

81303 87153 NCCI

81303 87158 NCCI

81303 87470 NCCI

81303 87471 NCCI

81303 87472 NCCI

81303 87475 NCCI

81303 87476 NCCI

81303 87477 NCCI

81303 87480 NCCI

81303 87481 NCCI

81303 87482 NCCI

81303 87483 NCCI

81303 87485 NCCI

81303 87486 NCCI

81303 87487 NCCI

81303 87490 NCCI

81303 87491 NCCI

81303 87492 NCCI

81303 87493 NCCI

81303 87495 NCCI

81303 87496 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 102 of 255

Page 103: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81303 87497 NCCI

81303 87498 NCCI

81303 87500 NCCI

81303 87501 NCCI

81303 87502 NCCI

81303 87503 NCCI

81303 87505 NCCI

81303 87506 NCCI

81303 87507 NCCI

81303 87510 NCCI

81303 87511 NCCI

81303 87512 NCCI

81303 87515 NCCI

81303 87516 NCCI

81303 87517 NCCI

81303 87520 NCCI

81303 87521 NCCI

81303 87522 NCCI

81303 87525 NCCI

81303 87526 NCCI

81303 87527 NCCI

81303 87528 NCCI

81303 87529 NCCI

81303 87530 NCCI

81303 87531 NCCI

81303 87532 NCCI

81303 87533 NCCI

81303 87534 NCCI

81303 87535 NCCI

81303 87536 NCCI

81303 87537 NCCI

81303 87538 NCCI

81303 87539 NCCI

81303 87540 NCCI

81303 87541 NCCI

81303 87542 NCCI

81303 87550 NCCI

81303 87551 NCCI

81303 87552 NCCI

81303 87555 NCCI

81303 87556 NCCI

81303 87557 NCCI

81303 87560 NCCI

81303 87561 NCCI

81303 87562 NCCI

81303 87580 NCCI

81303 87581 NCCI

Comprehensive ComponentCode Code Source

81303 87582 NCCI

81303 87590 NCCI

81303 87591 NCCI

81303 87592 NCCI

81303 87623 NCCI

81303 87624 NCCI

81303 87625 NCCI

81303 87631 NCCI

81303 87632 NCCI

81303 87633 NCCI

81303 87640 NCCI

81303 87641 NCCI

81303 87650 NCCI

81303 87651 NCCI

81303 87652 NCCI

81303 87653 NCCI

81303 87660 NCCI

81303 87661 NCCI

81303 87797 NCCI

81303 87798 NCCI

81303 87799 NCCI

81303 87800 NCCI

81303 87801 NCCI

81303 88271 NCCI

81303 88272 NCCI

81303 88273 NCCI

81303 88274 NCCI

81303 88275 NCCI

81303 88291 NCCI

81303 88364 NCCI

81303 88365 NCCI

81303 88366 NCCI

81303 88367 NCCI

81303 88368 NCCI

81303 88369 NCCI

81303 88373 NCCI

81303 88374 NCCI

81303 88377 NCCI

81303 G0476 NCCI

81304 80500 NCCI

81304 80502 NCCI

81304 84311 NCCI

81304 87140 NCCI

81304 87143 NCCI

81304 87147 NCCI

81304 87149 NCCI

81304 87150 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 103 of 255

Page 104: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81304 87152 NCCI

81304 87153 NCCI

81304 87158 NCCI

81304 87470 NCCI

81304 87471 NCCI

81304 87472 NCCI

81304 87475 NCCI

81304 87476 NCCI

81304 87477 NCCI

81304 87480 NCCI

81304 87481 NCCI

81304 87482 NCCI

81304 87483 NCCI

81304 87485 NCCI

81304 87486 NCCI

81304 87487 NCCI

81304 87490 NCCI

81304 87491 NCCI

81304 87492 NCCI

81304 87493 NCCI

81304 87495 NCCI

81304 87496 NCCI

81304 87497 NCCI

81304 87498 NCCI

81304 87500 NCCI

81304 87501 NCCI

81304 87502 NCCI

81304 87503 NCCI

81304 87505 NCCI

81304 87506 NCCI

81304 87507 NCCI

81304 87510 NCCI

81304 87511 NCCI

81304 87512 NCCI

81304 87515 NCCI

81304 87516 NCCI

81304 87517 NCCI

81304 87520 NCCI

81304 87521 NCCI

81304 87522 NCCI

81304 87525 NCCI

81304 87526 NCCI

81304 87527 NCCI

81304 87528 NCCI

81304 87529 NCCI

81304 87530 NCCI

81304 87531 NCCI

Comprehensive ComponentCode Code Source

81304 87532 NCCI

81304 87533 NCCI

81304 87534 NCCI

81304 87535 NCCI

81304 87536 NCCI

81304 87537 NCCI

81304 87538 NCCI

81304 87539 NCCI

81304 87540 NCCI

81304 87541 NCCI

81304 87542 NCCI

81304 87550 NCCI

81304 87551 NCCI

81304 87552 NCCI

81304 87555 NCCI

81304 87556 NCCI

81304 87557 NCCI

81304 87560 NCCI

81304 87561 NCCI

81304 87562 NCCI

81304 87580 NCCI

81304 87581 NCCI

81304 87582 NCCI

81304 87590 NCCI

81304 87591 NCCI

81304 87592 NCCI

81304 87623 NCCI

81304 87624 NCCI

81304 87625 NCCI

81304 87631 NCCI

81304 87632 NCCI

81304 87633 NCCI

81304 87640 NCCI

81304 87641 NCCI

81304 87650 NCCI

81304 87651 NCCI

81304 87652 NCCI

81304 87653 NCCI

81304 87660 NCCI

81304 87661 NCCI

81304 87797 NCCI

81304 87798 NCCI

81304 87799 NCCI

81304 87800 NCCI

81304 87801 NCCI

81304 88271 NCCI

81304 88272 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 104 of 255

Page 105: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81304 88273 NCCI

81304 88274 NCCI

81304 88275 NCCI

81304 88291 NCCI

81304 88364 NCCI

81304 88365 NCCI

81304 88366 NCCI

81304 88367 NCCI

81304 88368 NCCI

81304 88369 NCCI

81304 88373 NCCI

81304 88374 NCCI

81304 88377 NCCI

81304 G0476 NCCI

81310 80500 NCCI

81310 80502 NCCI

81310 84311 NCCI

81310 87140 NCCI

81310 87143 NCCI

81310 87147 NCCI

81310 87149 NCCI

81310 87150 NCCI

81310 87152 NCCI

81310 87153 NCCI

81310 87158 NCCI

81310 87470 NCCI

81310 87471 NCCI

81310 87472 NCCI

81310 87475 NCCI

81310 87476 NCCI

81310 87477 NCCI

81310 87480 NCCI

81310 87481 NCCI

81310 87482 NCCI

81310 87483 NCCI

81310 87485 NCCI

81310 87486 NCCI

81310 87487 NCCI

81310 87490 NCCI

81310 87491 NCCI

81310 87492 NCCI

81310 87493 NCCI

81310 87495 NCCI

81310 87496 NCCI

81310 87497 NCCI

81310 87498 NCCI

81310 87500 NCCI

Comprehensive ComponentCode Code Source

81310 87501 NCCI

81310 87502 NCCI

81310 87503 NCCI

81310 87505 NCCI

81310 87506 NCCI

81310 87507 NCCI

81310 87510 NCCI

81310 87511 NCCI

81310 87512 NCCI

81310 87515 NCCI

81310 87516 NCCI

81310 87517 NCCI

81310 87520 NCCI

81310 87521 NCCI

81310 87522 NCCI

81310 87525 NCCI

81310 87526 NCCI

81310 87527 NCCI

81310 87528 NCCI

81310 87529 NCCI

81310 87530 NCCI

81310 87531 NCCI

81310 87532 NCCI

81310 87533 NCCI

81310 87534 NCCI

81310 87535 NCCI

81310 87536 NCCI

81310 87537 NCCI

81310 87538 NCCI

81310 87539 NCCI

81310 87540 NCCI

81310 87541 NCCI

81310 87542 NCCI

81310 87550 NCCI

81310 87551 NCCI

81310 87552 NCCI

81310 87555 NCCI

81310 87556 NCCI

81310 87557 NCCI

81310 87560 NCCI

81310 87561 NCCI

81310 87562 NCCI

81310 87580 NCCI

81310 87581 NCCI

81310 87582 NCCI

81310 87590 NCCI

81310 87591 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 105 of 255

Page 106: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81310 87592 NCCI

81310 87623 NCCI

81310 87624 NCCI

81310 87625 NCCI

81310 87631 NCCI

81310 87632 NCCI

81310 87633 NCCI

81310 87640 NCCI

81310 87641 NCCI

81310 87650 NCCI

81310 87651 NCCI

81310 87652 NCCI

81310 87653 NCCI

81310 87660 NCCI

81310 87661 NCCI

81310 87797 NCCI

81310 87798 NCCI

81310 87799 NCCI

81310 87800 NCCI

81310 87801 NCCI

81310 88271 NCCI

81310 88272 NCCI

81310 88273 NCCI

81310 88274 NCCI

81310 88275 NCCI

81310 88291 NCCI

81310 88364 NCCI

81310 88365 NCCI

81310 88366 NCCI

81310 88367 NCCI

81310 88368 NCCI

81310 88369 NCCI

81310 88373 NCCI

81310 88374 NCCI

81310 88377 NCCI

81310 G0476 NCCI

81311 80500 NCCI

81311 80502 NCCI

81311 84311 NCCI

81311 87140 NCCI

81311 87143 NCCI

81311 87147 NCCI

81311 87149 NCCI

81311 87150 NCCI

81311 87152 NCCI

81311 87153 NCCI

81311 87158 NCCI

Comprehensive ComponentCode Code Source

81311 87470 NCCI

81311 87471 NCCI

81311 87472 NCCI

81311 87475 NCCI

81311 87476 NCCI

81311 87477 NCCI

81311 87480 NCCI

81311 87481 NCCI

81311 87482 NCCI

81311 87483 NCCI

81311 87485 NCCI

81311 87486 NCCI

81311 87487 NCCI

81311 87490 NCCI

81311 87491 NCCI

81311 87492 NCCI

81311 87493 NCCI

81311 87495 NCCI

81311 87496 NCCI

81311 87497 NCCI

81311 87498 NCCI

81311 87500 NCCI

81311 87501 NCCI

81311 87502 NCCI

81311 87503 NCCI

81311 87505 NCCI

81311 87506 NCCI

81311 87507 NCCI

81311 87510 NCCI

81311 87511 NCCI

81311 87512 NCCI

81311 87515 NCCI

81311 87516 NCCI

81311 87517 NCCI

81311 87520 NCCI

81311 87521 NCCI

81311 87522 NCCI

81311 87525 NCCI

81311 87526 NCCI

81311 87527 NCCI

81311 87528 NCCI

81311 87529 NCCI

81311 87530 NCCI

81311 87531 NCCI

81311 87532 NCCI

81311 87533 NCCI

81311 87534 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 106 of 255

Page 107: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81311 87535 NCCI

81311 87536 NCCI

81311 87537 NCCI

81311 87538 NCCI

81311 87539 NCCI

81311 87540 NCCI

81311 87541 NCCI

81311 87542 NCCI

81311 87550 NCCI

81311 87551 NCCI

81311 87552 NCCI

81311 87555 NCCI

81311 87556 NCCI

81311 87557 NCCI

81311 87560 NCCI

81311 87561 NCCI

81311 87562 NCCI

81311 87580 NCCI

81311 87581 NCCI

81311 87582 NCCI

81311 87590 NCCI

81311 87591 NCCI

81311 87592 NCCI

81311 87623 NCCI

81311 87624 NCCI

81311 87625 NCCI

81311 87631 NCCI

81311 87632 NCCI

81311 87633 NCCI

81311 87640 NCCI

81311 87641 NCCI

81311 87650 NCCI

81311 87651 NCCI

81311 87652 NCCI

81311 87653 NCCI

81311 87660 NCCI

81311 87661 NCCI

81311 87797 NCCI

81311 87798 NCCI

81311 87799 NCCI

81311 87800 NCCI

81311 87801 NCCI

81311 88271 NCCI

81311 88272 NCCI

81311 88273 NCCI

81311 88274 NCCI

81311 88275 NCCI

Comprehensive ComponentCode Code Source

81311 88291 NCCI

81311 88364 NCCI

81311 88365 NCCI

81311 88366 NCCI

81311 88367 NCCI

81311 88368 NCCI

81311 88369 NCCI

81311 88373 NCCI

81311 88374 NCCI

81311 88377 NCCI

81311 G0476 NCCI

81313 80500 NCCI

81313 80502 NCCI

81313 84311 NCCI

81313 87140 NCCI

81313 87143 NCCI

81313 87147 NCCI

81313 87149 NCCI

81313 87150 NCCI

81313 87152 NCCI

81313 87153 NCCI

81313 87158 NCCI

81313 87470 NCCI

81313 87471 NCCI

81313 87472 NCCI

81313 87475 NCCI

81313 87476 NCCI

81313 87477 NCCI

81313 87480 NCCI

81313 87481 NCCI

81313 87482 NCCI

81313 87483 NCCI

81313 87485 NCCI

81313 87486 NCCI

81313 87487 NCCI

81313 87490 NCCI

81313 87491 NCCI

81313 87492 NCCI

81313 87493 NCCI

81313 87495 NCCI

81313 87496 NCCI

81313 87497 NCCI

81313 87498 NCCI

81313 87500 NCCI

81313 87501 NCCI

81313 87502 NCCI

81313 87503 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 107 of 255

Page 108: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81313 87505 NCCI

81313 87506 NCCI

81313 87507 NCCI

81313 87510 NCCI

81313 87511 NCCI

81313 87512 NCCI

81313 87515 NCCI

81313 87516 NCCI

81313 87517 NCCI

81313 87520 NCCI

81313 87521 NCCI

81313 87522 NCCI

81313 87525 NCCI

81313 87526 NCCI

81313 87527 NCCI

81313 87528 NCCI

81313 87529 NCCI

81313 87530 NCCI

81313 87531 NCCI

81313 87532 NCCI

81313 87533 NCCI

81313 87534 NCCI

81313 87535 NCCI

81313 87536 NCCI

81313 87537 NCCI

81313 87538 NCCI

81313 87539 NCCI

81313 87540 NCCI

81313 87541 NCCI

81313 87542 NCCI

81313 87550 NCCI

81313 87551 NCCI

81313 87552 NCCI

81313 87555 NCCI

81313 87556 NCCI

81313 87557 NCCI

81313 87560 NCCI

81313 87561 NCCI

81313 87562 NCCI

81313 87580 NCCI

81313 87581 NCCI

81313 87582 NCCI

81313 87590 NCCI

81313 87591 NCCI

81313 87592 NCCI

81313 87623 NCCI

81313 87624 NCCI

Comprehensive ComponentCode Code Source

81313 87625 NCCI

81313 87631 NCCI

81313 87632 NCCI

81313 87633 NCCI

81313 87640 NCCI

81313 87641 NCCI

81313 87650 NCCI

81313 87651 NCCI

81313 87652 NCCI

81313 87653 NCCI

81313 87660 NCCI

81313 87661 NCCI

81313 87797 NCCI

81313 87798 NCCI

81313 87799 NCCI

81313 87800 NCCI

81313 87801 NCCI

81313 88271 NCCI

81313 88272 NCCI

81313 88273 NCCI

81313 88274 NCCI

81313 88275 NCCI

81313 88291 NCCI

81313 88364 NCCI

81313 88365 NCCI

81313 88366 NCCI

81313 88367 NCCI

81313 88368 NCCI

81313 88369 NCCI

81313 88373 NCCI

81313 88374 NCCI

81313 88377 NCCI

81313 G0476 NCCI

81314 80500 NCCI

81314 80502 NCCI

81314 84311 NCCI

81314 87140 NCCI

81314 87143 NCCI

81314 87147 NCCI

81314 87149 NCCI

81314 87150 NCCI

81314 87152 NCCI

81314 87153 NCCI

81314 87158 NCCI

81314 87470 NCCI

81314 87471 NCCI

81314 87472 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 108 of 255

Page 109: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81314 87475 NCCI

81314 87476 NCCI

81314 87477 NCCI

81314 87480 NCCI

81314 87481 NCCI

81314 87482 NCCI

81314 87483 NCCI

81314 87485 NCCI

81314 87486 NCCI

81314 87487 NCCI

81314 87490 NCCI

81314 87491 NCCI

81314 87492 NCCI

81314 87493 NCCI

81314 87495 NCCI

81314 87496 NCCI

81314 87497 NCCI

81314 87498 NCCI

81314 87500 NCCI

81314 87501 NCCI

81314 87502 NCCI

81314 87503 NCCI

81314 87505 NCCI

81314 87506 NCCI

81314 87507 NCCI

81314 87510 NCCI

81314 87511 NCCI

81314 87512 NCCI

81314 87515 NCCI

81314 87516 NCCI

81314 87517 NCCI

81314 87520 NCCI

81314 87521 NCCI

81314 87522 NCCI

81314 87525 NCCI

81314 87526 NCCI

81314 87527 NCCI

81314 87528 NCCI

81314 87529 NCCI

81314 87530 NCCI

81314 87531 NCCI

81314 87532 NCCI

81314 87533 NCCI

81314 87534 NCCI

81314 87535 NCCI

81314 87536 NCCI

81314 87537 NCCI

Comprehensive ComponentCode Code Source

81314 87538 NCCI

81314 87539 NCCI

81314 87540 NCCI

81314 87541 NCCI

81314 87542 NCCI

81314 87550 NCCI

81314 87551 NCCI

81314 87552 NCCI

81314 87555 NCCI

81314 87556 NCCI

81314 87557 NCCI

81314 87560 NCCI

81314 87561 NCCI

81314 87562 NCCI

81314 87580 NCCI

81314 87581 NCCI

81314 87582 NCCI

81314 87590 NCCI

81314 87591 NCCI

81314 87592 NCCI

81314 87623 NCCI

81314 87624 NCCI

81314 87625 NCCI

81314 87631 NCCI

81314 87632 NCCI

81314 87633 NCCI

81314 87640 NCCI

81314 87641 NCCI

81314 87650 NCCI

81314 87651 NCCI

81314 87652 NCCI

81314 87653 NCCI

81314 87660 NCCI

81314 87661 NCCI

81314 87797 NCCI

81314 87798 NCCI

81314 87799 NCCI

81314 87800 NCCI

81314 87801 NCCI

81314 88271 NCCI

81314 88272 NCCI

81314 88273 NCCI

81314 88274 NCCI

81314 88275 NCCI

81314 88291 NCCI

81314 88364 NCCI

81314 88365 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 109 of 255

Page 110: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81314 88366 NCCI

81314 88367 NCCI

81314 88368 NCCI

81314 88369 NCCI

81314 88373 NCCI

81314 88374 NCCI

81314 88377 NCCI

81314 G0476 NCCI

81315 80500 NCCI

81315 80502 NCCI

81315 81316 NCCI

81315 84311 NCCI

81315 87140 NCCI

81315 87143 NCCI

81315 87147 NCCI

81315 87149 NCCI

81315 87150 NCCI

81315 87152 NCCI

81315 87153 NCCI

81315 87158 NCCI

81315 87470 NCCI

81315 87471 NCCI

81315 87472 NCCI

81315 87475 NCCI

81315 87476 NCCI

81315 87477 NCCI

81315 87480 NCCI

81315 87481 NCCI

81315 87482 NCCI

81315 87483 NCCI

81315 87485 NCCI

81315 87486 NCCI

81315 87487 NCCI

81315 87490 NCCI

81315 87491 NCCI

81315 87492 NCCI

81315 87493 NCCI

81315 87495 NCCI

81315 87496 NCCI

81315 87497 NCCI

81315 87498 NCCI

81315 87500 NCCI

81315 87501 NCCI

81315 87502 NCCI

81315 87503 NCCI

81315 87505 NCCI

81315 87506 NCCI

Comprehensive ComponentCode Code Source

81315 87507 NCCI

81315 87510 NCCI

81315 87511 NCCI

81315 87512 NCCI

81315 87515 NCCI

81315 87516 NCCI

81315 87517 NCCI

81315 87520 NCCI

81315 87521 NCCI

81315 87522 NCCI

81315 87525 NCCI

81315 87526 NCCI

81315 87527 NCCI

81315 87528 NCCI

81315 87529 NCCI

81315 87530 NCCI

81315 87531 NCCI

81315 87532 NCCI

81315 87533 NCCI

81315 87534 NCCI

81315 87535 NCCI

81315 87536 NCCI

81315 87537 NCCI

81315 87538 NCCI

81315 87539 NCCI

81315 87540 NCCI

81315 87541 NCCI

81315 87542 NCCI

81315 87550 NCCI

81315 87551 NCCI

81315 87552 NCCI

81315 87555 NCCI

81315 87556 NCCI

81315 87557 NCCI

81315 87560 NCCI

81315 87561 NCCI

81315 87562 NCCI

81315 87580 NCCI

81315 87581 NCCI

81315 87582 NCCI

81315 87590 NCCI

81315 87591 NCCI

81315 87592 NCCI

81315 87623 NCCI

81315 87624 NCCI

81315 87625 NCCI

81315 87631 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 110 of 255

Page 111: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81315 87632 NCCI

81315 87633 NCCI

81315 87640 NCCI

81315 87641 NCCI

81315 87650 NCCI

81315 87651 NCCI

81315 87652 NCCI

81315 87653 NCCI

81315 87660 NCCI

81315 87661 NCCI

81315 87797 NCCI

81315 87798 NCCI

81315 87799 NCCI

81315 87800 NCCI

81315 87801 NCCI

81315 88271 NCCI

81315 88272 NCCI

81315 88273 NCCI

81315 88274 NCCI

81315 88275 NCCI

81315 88291 NCCI

81315 88364 NCCI

81315 88365 NCCI

81315 88366 NCCI

81315 88367 NCCI

81315 88368 NCCI

81315 88369 NCCI

81315 88373 NCCI

81315 88374 NCCI

81315 88377 NCCI

81315 G0476 NCCI

81316 80500 NCCI

81316 80502 NCCI

81316 84311 NCCI

81316 87140 NCCI

81316 87143 NCCI

81316 87147 NCCI

81316 87149 NCCI

81316 87150 NCCI

81316 87152 NCCI

81316 87153 NCCI

81316 87158 NCCI

81316 87470 NCCI

81316 87471 NCCI

81316 87472 NCCI

81316 87475 NCCI

81316 87476 NCCI

Comprehensive ComponentCode Code Source

81316 87477 NCCI

81316 87480 NCCI

81316 87481 NCCI

81316 87482 NCCI

81316 87483 NCCI

81316 87485 NCCI

81316 87486 NCCI

81316 87487 NCCI

81316 87490 NCCI

81316 87491 NCCI

81316 87492 NCCI

81316 87493 NCCI

81316 87495 NCCI

81316 87496 NCCI

81316 87497 NCCI

81316 87498 NCCI

81316 87500 NCCI

81316 87501 NCCI

81316 87502 NCCI

81316 87503 NCCI

81316 87505 NCCI

81316 87506 NCCI

81316 87507 NCCI

81316 87510 NCCI

81316 87511 NCCI

81316 87512 NCCI

81316 87515 NCCI

81316 87516 NCCI

81316 87517 NCCI

81316 87520 NCCI

81316 87521 NCCI

81316 87522 NCCI

81316 87525 NCCI

81316 87526 NCCI

81316 87527 NCCI

81316 87528 NCCI

81316 87529 NCCI

81316 87530 NCCI

81316 87531 NCCI

81316 87532 NCCI

81316 87533 NCCI

81316 87534 NCCI

81316 87535 NCCI

81316 87536 NCCI

81316 87537 NCCI

81316 87538 NCCI

81316 87539 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 111 of 255

Page 112: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81316 87540 NCCI

81316 87541 NCCI

81316 87542 NCCI

81316 87550 NCCI

81316 87551 NCCI

81316 87552 NCCI

81316 87555 NCCI

81316 87556 NCCI

81316 87557 NCCI

81316 87560 NCCI

81316 87561 NCCI

81316 87562 NCCI

81316 87580 NCCI

81316 87581 NCCI

81316 87582 NCCI

81316 87590 NCCI

81316 87591 NCCI

81316 87592 NCCI

81316 87623 NCCI

81316 87624 NCCI

81316 87625 NCCI

81316 87631 NCCI

81316 87632 NCCI

81316 87633 NCCI

81316 87640 NCCI

81316 87641 NCCI

81316 87650 NCCI

81316 87651 NCCI

81316 87652 NCCI

81316 87653 NCCI

81316 87660 NCCI

81316 87661 NCCI

81316 87797 NCCI

81316 87798 NCCI

81316 87799 NCCI

81316 87800 NCCI

81316 87801 NCCI

81316 88271 NCCI

81316 88272 NCCI

81316 88273 NCCI

81316 88274 NCCI

81316 88275 NCCI

81316 88291 NCCI

81316 88364 NCCI

81316 88365 NCCI

81316 88366 NCCI

81316 88367 NCCI

Comprehensive ComponentCode Code Source

81316 88368 NCCI

81316 88369 NCCI

81316 88373 NCCI

81316 88374 NCCI

81316 88377 NCCI

81316 G0476 NCCI

81317 80500 NCCI

81317 80502 NCCI

81317 81318 NCCI

81317 81319 NCCI

81317 84311 NCCI

81317 87140 NCCI

81317 87143 NCCI

81317 87147 NCCI

81317 87149 NCCI

81317 87150 NCCI

81317 87152 NCCI

81317 87153 NCCI

81317 87158 NCCI

81317 87470 NCCI

81317 87471 NCCI

81317 87472 NCCI

81317 87475 NCCI

81317 87476 NCCI

81317 87477 NCCI

81317 87480 NCCI

81317 87481 NCCI

81317 87482 NCCI

81317 87483 NCCI

81317 87485 NCCI

81317 87486 NCCI

81317 87487 NCCI

81317 87490 NCCI

81317 87491 NCCI

81317 87492 NCCI

81317 87493 NCCI

81317 87495 NCCI

81317 87496 NCCI

81317 87497 NCCI

81317 87498 NCCI

81317 87500 NCCI

81317 87501 NCCI

81317 87502 NCCI

81317 87503 NCCI

81317 87505 NCCI

81317 87506 NCCI

81317 87507 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 112 of 255

Page 113: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81317 87510 NCCI

81317 87511 NCCI

81317 87512 NCCI

81317 87515 NCCI

81317 87516 NCCI

81317 87517 NCCI

81317 87520 NCCI

81317 87521 NCCI

81317 87522 NCCI

81317 87525 NCCI

81317 87526 NCCI

81317 87527 NCCI

81317 87528 NCCI

81317 87529 NCCI

81317 87530 NCCI

81317 87531 NCCI

81317 87532 NCCI

81317 87533 NCCI

81317 87534 NCCI

81317 87535 NCCI

81317 87536 NCCI

81317 87537 NCCI

81317 87538 NCCI

81317 87539 NCCI

81317 87540 NCCI

81317 87541 NCCI

81317 87542 NCCI

81317 87550 NCCI

81317 87551 NCCI

81317 87552 NCCI

81317 87555 NCCI

81317 87556 NCCI

81317 87557 NCCI

81317 87560 NCCI

81317 87561 NCCI

81317 87562 NCCI

81317 87580 NCCI

81317 87581 NCCI

81317 87582 NCCI

81317 87590 NCCI

81317 87591 NCCI

81317 87592 NCCI

81317 87623 NCCI

81317 87624 NCCI

81317 87625 NCCI

81317 87631 NCCI

81317 87632 NCCI

Comprehensive ComponentCode Code Source

81317 87633 NCCI

81317 87640 NCCI

81317 87641 NCCI

81317 87650 NCCI

81317 87651 NCCI

81317 87652 NCCI

81317 87653 NCCI

81317 87660 NCCI

81317 87661 NCCI

81317 87797 NCCI

81317 87798 NCCI

81317 87799 NCCI

81317 87800 NCCI

81317 87801 NCCI

81317 88271 NCCI

81317 88272 NCCI

81317 88273 NCCI

81317 88274 NCCI

81317 88275 NCCI

81317 88291 NCCI

81317 88364 NCCI

81317 88365 NCCI

81317 88366 NCCI

81317 88367 NCCI

81317 88368 NCCI

81317 88369 NCCI

81317 88373 NCCI

81317 88374 NCCI

81317 88377 NCCI

81317 G0476 NCCI

81318 80500 NCCI

81318 80502 NCCI

81318 81319 NCCI

81318 84311 NCCI

81318 87140 NCCI

81318 87143 NCCI

81318 87147 NCCI

81318 87149 NCCI

81318 87150 NCCI

81318 87152 NCCI

81318 87153 NCCI

81318 87158 NCCI

81318 87470 NCCI

81318 87471 NCCI

81318 87472 NCCI

81318 87475 NCCI

81318 87476 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 113 of 255

Page 114: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81318 87477 NCCI

81318 87480 NCCI

81318 87481 NCCI

81318 87482 NCCI

81318 87483 NCCI

81318 87485 NCCI

81318 87486 NCCI

81318 87487 NCCI

81318 87490 NCCI

81318 87491 NCCI

81318 87492 NCCI

81318 87493 NCCI

81318 87495 NCCI

81318 87496 NCCI

81318 87497 NCCI

81318 87498 NCCI

81318 87500 NCCI

81318 87501 NCCI

81318 87502 NCCI

81318 87503 NCCI

81318 87505 NCCI

81318 87506 NCCI

81318 87507 NCCI

81318 87510 NCCI

81318 87511 NCCI

81318 87512 NCCI

81318 87515 NCCI

81318 87516 NCCI

81318 87517 NCCI

81318 87520 NCCI

81318 87521 NCCI

81318 87522 NCCI

81318 87525 NCCI

81318 87526 NCCI

81318 87527 NCCI

81318 87528 NCCI

81318 87529 NCCI

81318 87530 NCCI

81318 87531 NCCI

81318 87532 NCCI

81318 87533 NCCI

81318 87534 NCCI

81318 87535 NCCI

81318 87536 NCCI

81318 87537 NCCI

81318 87538 NCCI

81318 87539 NCCI

Comprehensive ComponentCode Code Source

81318 87540 NCCI

81318 87541 NCCI

81318 87542 NCCI

81318 87550 NCCI

81318 87551 NCCI

81318 87552 NCCI

81318 87555 NCCI

81318 87556 NCCI

81318 87557 NCCI

81318 87560 NCCI

81318 87561 NCCI

81318 87562 NCCI

81318 87580 NCCI

81318 87581 NCCI

81318 87582 NCCI

81318 87590 NCCI

81318 87591 NCCI

81318 87592 NCCI

81318 87623 NCCI

81318 87624 NCCI

81318 87625 NCCI

81318 87631 NCCI

81318 87632 NCCI

81318 87633 NCCI

81318 87640 NCCI

81318 87641 NCCI

81318 87650 NCCI

81318 87651 NCCI

81318 87652 NCCI

81318 87653 NCCI

81318 87660 NCCI

81318 87661 NCCI

81318 87797 NCCI

81318 87798 NCCI

81318 87799 NCCI

81318 87800 NCCI

81318 87801 NCCI

81318 88271 NCCI

81318 88272 NCCI

81318 88273 NCCI

81318 88274 NCCI

81318 88275 NCCI

81318 88291 NCCI

81318 88364 NCCI

81318 88365 NCCI

81318 88366 NCCI

81318 88367 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 114 of 255

Page 115: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81318 88368 NCCI

81318 88369 NCCI

81318 88373 NCCI

81318 88374 NCCI

81318 88377 NCCI

81318 G0476 NCCI

81319 80500 NCCI

81319 80502 NCCI

81319 84311 NCCI

81319 87140 NCCI

81319 87143 NCCI

81319 87147 NCCI

81319 87149 NCCI

81319 87150 NCCI

81319 87152 NCCI

81319 87153 NCCI

81319 87158 NCCI

81319 87470 NCCI

81319 87471 NCCI

81319 87472 NCCI

81319 87475 NCCI

81319 87476 NCCI

81319 87477 NCCI

81319 87480 NCCI

81319 87481 NCCI

81319 87482 NCCI

81319 87483 NCCI

81319 87485 NCCI

81319 87486 NCCI

81319 87487 NCCI

81319 87490 NCCI

81319 87491 NCCI

81319 87492 NCCI

81319 87493 NCCI

81319 87495 NCCI

81319 87496 NCCI

81319 87497 NCCI

81319 87498 NCCI

81319 87500 NCCI

81319 87501 NCCI

81319 87502 NCCI

81319 87503 NCCI

81319 87505 NCCI

81319 87506 NCCI

81319 87507 NCCI

81319 87510 NCCI

81319 87511 NCCI

Comprehensive ComponentCode Code Source

81319 87512 NCCI

81319 87515 NCCI

81319 87516 NCCI

81319 87517 NCCI

81319 87520 NCCI

81319 87521 NCCI

81319 87522 NCCI

81319 87525 NCCI

81319 87526 NCCI

81319 87527 NCCI

81319 87528 NCCI

81319 87529 NCCI

81319 87530 NCCI

81319 87531 NCCI

81319 87532 NCCI

81319 87533 NCCI

81319 87534 NCCI

81319 87535 NCCI

81319 87536 NCCI

81319 87537 NCCI

81319 87538 NCCI

81319 87539 NCCI

81319 87540 NCCI

81319 87541 NCCI

81319 87542 NCCI

81319 87550 NCCI

81319 87551 NCCI

81319 87552 NCCI

81319 87555 NCCI

81319 87556 NCCI

81319 87557 NCCI

81319 87560 NCCI

81319 87561 NCCI

81319 87562 NCCI

81319 87580 NCCI

81319 87581 NCCI

81319 87582 NCCI

81319 87590 NCCI

81319 87591 NCCI

81319 87592 NCCI

81319 87623 NCCI

81319 87624 NCCI

81319 87625 NCCI

81319 87631 NCCI

81319 87632 NCCI

81319 87633 NCCI

81319 87640 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 115 of 255

Page 116: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81319 87641 NCCI

81319 87650 NCCI

81319 87651 NCCI

81319 87652 NCCI

81319 87653 NCCI

81319 87660 NCCI

81319 87661 NCCI

81319 87797 NCCI

81319 87798 NCCI

81319 87799 NCCI

81319 87800 NCCI

81319 87801 NCCI

81319 88271 NCCI

81319 88272 NCCI

81319 88273 NCCI

81319 88274 NCCI

81319 88275 NCCI

81319 88291 NCCI

81319 88364 NCCI

81319 88365 NCCI

81319 88366 NCCI

81319 88367 NCCI

81319 88368 NCCI

81319 88369 NCCI

81319 88373 NCCI

81319 88374 NCCI

81319 88377 NCCI

81319 G0476 NCCI

81321 80500 NCCI

81321 80502 NCCI

81321 81322 NCCI

81321 81323 NCCI

81321 84311 NCCI

81321 87140 NCCI

81321 87143 NCCI

81321 87147 NCCI

81321 87149 NCCI

81321 87150 NCCI

81321 87152 NCCI

81321 87153 NCCI

81321 87158 NCCI

81321 87470 NCCI

81321 87471 NCCI

81321 87472 NCCI

81321 87475 NCCI

81321 87476 NCCI

81321 87477 NCCI

Comprehensive ComponentCode Code Source

81321 87480 NCCI

81321 87481 NCCI

81321 87482 NCCI

81321 87483 NCCI

81321 87485 NCCI

81321 87486 NCCI

81321 87487 NCCI

81321 87490 NCCI

81321 87491 NCCI

81321 87492 NCCI

81321 87493 NCCI

81321 87495 NCCI

81321 87496 NCCI

81321 87497 NCCI

81321 87498 NCCI

81321 87500 NCCI

81321 87501 NCCI

81321 87502 NCCI

81321 87503 NCCI

81321 87505 NCCI

81321 87506 NCCI

81321 87507 NCCI

81321 87510 NCCI

81321 87511 NCCI

81321 87512 NCCI

81321 87515 NCCI

81321 87516 NCCI

81321 87517 NCCI

81321 87520 NCCI

81321 87521 NCCI

81321 87522 NCCI

81321 87525 NCCI

81321 87526 NCCI

81321 87527 NCCI

81321 87528 NCCI

81321 87529 NCCI

81321 87530 NCCI

81321 87531 NCCI

81321 87532 NCCI

81321 87533 NCCI

81321 87534 NCCI

81321 87535 NCCI

81321 87536 NCCI

81321 87537 NCCI

81321 87538 NCCI

81321 87539 NCCI

81321 87540 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 116 of 255

Page 117: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81321 87541 NCCI

81321 87542 NCCI

81321 87550 NCCI

81321 87551 NCCI

81321 87552 NCCI

81321 87555 NCCI

81321 87556 NCCI

81321 87557 NCCI

81321 87560 NCCI

81321 87561 NCCI

81321 87562 NCCI

81321 87580 NCCI

81321 87581 NCCI

81321 87582 NCCI

81321 87590 NCCI

81321 87591 NCCI

81321 87592 NCCI

81321 87623 NCCI

81321 87624 NCCI

81321 87625 NCCI

81321 87631 NCCI

81321 87632 NCCI

81321 87633 NCCI

81321 87640 NCCI

81321 87641 NCCI

81321 87650 NCCI

81321 87651 NCCI

81321 87652 NCCI

81321 87653 NCCI

81321 87660 NCCI

81321 87661 NCCI

81321 87797 NCCI

81321 87798 NCCI

81321 87799 NCCI

81321 87800 NCCI

81321 87801 NCCI

81321 88271 NCCI

81321 88272 NCCI

81321 88273 NCCI

81321 88274 NCCI

81321 88275 NCCI

81321 88291 NCCI

81321 88364 NCCI

81321 88365 NCCI

81321 88366 NCCI

81321 88367 NCCI

81321 88368 NCCI

Comprehensive ComponentCode Code Source

81321 88369 NCCI

81321 88373 NCCI

81321 88374 NCCI

81321 88377 NCCI

81321 G0476 NCCI

81322 80500 NCCI

81322 80502 NCCI

81322 81323 NCCI

81322 84311 NCCI

81322 87140 NCCI

81322 87143 NCCI

81322 87147 NCCI

81322 87149 NCCI

81322 87150 NCCI

81322 87152 NCCI

81322 87153 NCCI

81322 87158 NCCI

81322 87470 NCCI

81322 87471 NCCI

81322 87472 NCCI

81322 87475 NCCI

81322 87476 NCCI

81322 87477 NCCI

81322 87480 NCCI

81322 87481 NCCI

81322 87482 NCCI

81322 87483 NCCI

81322 87485 NCCI

81322 87486 NCCI

81322 87487 NCCI

81322 87490 NCCI

81322 87491 NCCI

81322 87492 NCCI

81322 87493 NCCI

81322 87495 NCCI

81322 87496 NCCI

81322 87497 NCCI

81322 87498 NCCI

81322 87500 NCCI

81322 87501 NCCI

81322 87502 NCCI

81322 87503 NCCI

81322 87505 NCCI

81322 87506 NCCI

81322 87507 NCCI

81322 87510 NCCI

81322 87511 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 117 of 255

Page 118: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81322 87512 NCCI

81322 87515 NCCI

81322 87516 NCCI

81322 87517 NCCI

81322 87520 NCCI

81322 87521 NCCI

81322 87522 NCCI

81322 87525 NCCI

81322 87526 NCCI

81322 87527 NCCI

81322 87528 NCCI

81322 87529 NCCI

81322 87530 NCCI

81322 87531 NCCI

81322 87532 NCCI

81322 87533 NCCI

81322 87534 NCCI

81322 87535 NCCI

81322 87536 NCCI

81322 87537 NCCI

81322 87538 NCCI

81322 87539 NCCI

81322 87540 NCCI

81322 87541 NCCI

81322 87542 NCCI

81322 87550 NCCI

81322 87551 NCCI

81322 87552 NCCI

81322 87555 NCCI

81322 87556 NCCI

81322 87557 NCCI

81322 87560 NCCI

81322 87561 NCCI

81322 87562 NCCI

81322 87580 NCCI

81322 87581 NCCI

81322 87582 NCCI

81322 87590 NCCI

81322 87591 NCCI

81322 87592 NCCI

81322 87623 NCCI

81322 87624 NCCI

81322 87625 NCCI

81322 87631 NCCI

81322 87632 NCCI

81322 87633 NCCI

81322 87640 NCCI

Comprehensive ComponentCode Code Source

81322 87641 NCCI

81322 87650 NCCI

81322 87651 NCCI

81322 87652 NCCI

81322 87653 NCCI

81322 87660 NCCI

81322 87661 NCCI

81322 87797 NCCI

81322 87798 NCCI

81322 87799 NCCI

81322 87800 NCCI

81322 87801 NCCI

81322 88271 NCCI

81322 88272 NCCI

81322 88273 NCCI

81322 88274 NCCI

81322 88275 NCCI

81322 88291 NCCI

81322 88364 NCCI

81322 88365 NCCI

81322 88366 NCCI

81322 88367 NCCI

81322 88368 NCCI

81322 88369 NCCI

81322 88373 NCCI

81322 88374 NCCI

81322 88377 NCCI

81322 G0476 NCCI

81323 80500 NCCI

81323 80502 NCCI

81323 84311 NCCI

81323 87140 NCCI

81323 87143 NCCI

81323 87147 NCCI

81323 87149 NCCI

81323 87150 NCCI

81323 87152 NCCI

81323 87153 NCCI

81323 87158 NCCI

81323 87470 NCCI

81323 87471 NCCI

81323 87472 NCCI

81323 87475 NCCI

81323 87476 NCCI

81323 87477 NCCI

81323 87480 NCCI

81323 87481 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 118 of 255

Page 119: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81323 87482 NCCI

81323 87483 NCCI

81323 87485 NCCI

81323 87486 NCCI

81323 87487 NCCI

81323 87490 NCCI

81323 87491 NCCI

81323 87492 NCCI

81323 87493 NCCI

81323 87495 NCCI

81323 87496 NCCI

81323 87497 NCCI

81323 87498 NCCI

81323 87500 NCCI

81323 87501 NCCI

81323 87502 NCCI

81323 87503 NCCI

81323 87505 NCCI

81323 87506 NCCI

81323 87507 NCCI

81323 87510 NCCI

81323 87511 NCCI

81323 87512 NCCI

81323 87515 NCCI

81323 87516 NCCI

81323 87517 NCCI

81323 87520 NCCI

81323 87521 NCCI

81323 87522 NCCI

81323 87525 NCCI

81323 87526 NCCI

81323 87527 NCCI

81323 87528 NCCI

81323 87529 NCCI

81323 87530 NCCI

81323 87531 NCCI

81323 87532 NCCI

81323 87533 NCCI

81323 87534 NCCI

81323 87535 NCCI

81323 87536 NCCI

81323 87537 NCCI

81323 87538 NCCI

81323 87539 NCCI

81323 87540 NCCI

81323 87541 NCCI

81323 87542 NCCI

Comprehensive ComponentCode Code Source

81323 87550 NCCI

81323 87551 NCCI

81323 87552 NCCI

81323 87555 NCCI

81323 87556 NCCI

81323 87557 NCCI

81323 87560 NCCI

81323 87561 NCCI

81323 87562 NCCI

81323 87580 NCCI

81323 87581 NCCI

81323 87582 NCCI

81323 87590 NCCI

81323 87591 NCCI

81323 87592 NCCI

81323 87623 NCCI

81323 87624 NCCI

81323 87625 NCCI

81323 87631 NCCI

81323 87632 NCCI

81323 87633 NCCI

81323 87640 NCCI

81323 87641 NCCI

81323 87650 NCCI

81323 87651 NCCI

81323 87652 NCCI

81323 87653 NCCI

81323 87660 NCCI

81323 87661 NCCI

81323 87797 NCCI

81323 87798 NCCI

81323 87799 NCCI

81323 87800 NCCI

81323 87801 NCCI

81323 88271 NCCI

81323 88272 NCCI

81323 88273 NCCI

81323 88274 NCCI

81323 88275 NCCI

81323 88291 NCCI

81323 88364 NCCI

81323 88365 NCCI

81323 88366 NCCI

81323 88367 NCCI

81323 88368 NCCI

81323 88369 NCCI

81323 88373 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 119 of 255

Page 120: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81323 88374 NCCI

81323 88377 NCCI

81323 G0476 NCCI

81324 80500 NCCI

81324 80502 NCCI

81324 81326 NCCI

81324 84311 NCCI

81324 87140 NCCI

81324 87143 NCCI

81324 87147 NCCI

81324 87149 NCCI

81324 87150 NCCI

81324 87152 NCCI

81324 87153 NCCI

81324 87158 NCCI

81324 87470 NCCI

81324 87471 NCCI

81324 87472 NCCI

81324 87475 NCCI

81324 87476 NCCI

81324 87477 NCCI

81324 87480 NCCI

81324 87481 NCCI

81324 87482 NCCI

81324 87483 NCCI

81324 87485 NCCI

81324 87486 NCCI

81324 87487 NCCI

81324 87490 NCCI

81324 87491 NCCI

81324 87492 NCCI

81324 87493 NCCI

81324 87495 NCCI

81324 87496 NCCI

81324 87497 NCCI

81324 87498 NCCI

81324 87500 NCCI

81324 87501 NCCI

81324 87502 NCCI

81324 87503 NCCI

81324 87505 NCCI

81324 87506 NCCI

81324 87507 NCCI

81324 87510 NCCI

81324 87511 NCCI

81324 87512 NCCI

81324 87515 NCCI

Comprehensive ComponentCode Code Source

81324 87516 NCCI

81324 87517 NCCI

81324 87520 NCCI

81324 87521 NCCI

81324 87522 NCCI

81324 87525 NCCI

81324 87526 NCCI

81324 87527 NCCI

81324 87528 NCCI

81324 87529 NCCI

81324 87530 NCCI

81324 87531 NCCI

81324 87532 NCCI

81324 87533 NCCI

81324 87534 NCCI

81324 87535 NCCI

81324 87536 NCCI

81324 87537 NCCI

81324 87538 NCCI

81324 87539 NCCI

81324 87540 NCCI

81324 87541 NCCI

81324 87542 NCCI

81324 87550 NCCI

81324 87551 NCCI

81324 87552 NCCI

81324 87555 NCCI

81324 87556 NCCI

81324 87557 NCCI

81324 87560 NCCI

81324 87561 NCCI

81324 87562 NCCI

81324 87580 NCCI

81324 87581 NCCI

81324 87582 NCCI

81324 87590 NCCI

81324 87591 NCCI

81324 87592 NCCI

81324 87623 NCCI

81324 87624 NCCI

81324 87625 NCCI

81324 87631 NCCI

81324 87632 NCCI

81324 87633 NCCI

81324 87640 NCCI

81324 87641 NCCI

81324 87650 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 120 of 255

Page 121: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81324 87651 NCCI

81324 87652 NCCI

81324 87653 NCCI

81324 87660 NCCI

81324 87661 NCCI

81324 87797 NCCI

81324 87798 NCCI

81324 87799 NCCI

81324 87800 NCCI

81324 87801 NCCI

81324 88271 NCCI

81324 88272 NCCI

81324 88273 NCCI

81324 88274 NCCI

81324 88275 NCCI

81324 88291 NCCI

81324 88364 NCCI

81324 88365 NCCI

81324 88366 NCCI

81324 88367 NCCI

81324 88368 NCCI

81324 88369 NCCI

81324 88373 NCCI

81324 88374 NCCI

81324 88377 NCCI

81324 G0476 NCCI

81325 80500 NCCI

81325 80502 NCCI

81325 81324 NCCI

81325 81326 NCCI

81325 84311 NCCI

81325 87140 NCCI

81325 87143 NCCI

81325 87147 NCCI

81325 87149 NCCI

81325 87150 NCCI

81325 87152 NCCI

81325 87153 NCCI

81325 87158 NCCI

81325 87470 NCCI

81325 87471 NCCI

81325 87472 NCCI

81325 87475 NCCI

81325 87476 NCCI

81325 87477 NCCI

81325 87480 NCCI

81325 87481 NCCI

Comprehensive ComponentCode Code Source

81325 87482 NCCI

81325 87483 NCCI

81325 87485 NCCI

81325 87486 NCCI

81325 87487 NCCI

81325 87490 NCCI

81325 87491 NCCI

81325 87492 NCCI

81325 87493 NCCI

81325 87495 NCCI

81325 87496 NCCI

81325 87497 NCCI

81325 87498 NCCI

81325 87500 NCCI

81325 87501 NCCI

81325 87502 NCCI

81325 87503 NCCI

81325 87505 NCCI

81325 87506 NCCI

81325 87507 NCCI

81325 87510 NCCI

81325 87511 NCCI

81325 87512 NCCI

81325 87515 NCCI

81325 87516 NCCI

81325 87517 NCCI

81325 87520 NCCI

81325 87521 NCCI

81325 87522 NCCI

81325 87525 NCCI

81325 87526 NCCI

81325 87527 NCCI

81325 87528 NCCI

81325 87529 NCCI

81325 87530 NCCI

81325 87531 NCCI

81325 87532 NCCI

81325 87533 NCCI

81325 87534 NCCI

81325 87535 NCCI

81325 87536 NCCI

81325 87537 NCCI

81325 87538 NCCI

81325 87539 NCCI

81325 87540 NCCI

81325 87541 NCCI

81325 87542 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 121 of 255

Page 122: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81325 87550 NCCI

81325 87551 NCCI

81325 87552 NCCI

81325 87555 NCCI

81325 87556 NCCI

81325 87557 NCCI

81325 87560 NCCI

81325 87561 NCCI

81325 87562 NCCI

81325 87580 NCCI

81325 87581 NCCI

81325 87582 NCCI

81325 87590 NCCI

81325 87591 NCCI

81325 87592 NCCI

81325 87623 NCCI

81325 87624 NCCI

81325 87625 NCCI

81325 87631 NCCI

81325 87632 NCCI

81325 87633 NCCI

81325 87640 NCCI

81325 87641 NCCI

81325 87650 NCCI

81325 87651 NCCI

81325 87652 NCCI

81325 87653 NCCI

81325 87660 NCCI

81325 87661 NCCI

81325 87797 NCCI

81325 87798 NCCI

81325 87799 NCCI

81325 87800 NCCI

81325 87801 NCCI

81325 88271 NCCI

81325 88272 NCCI

81325 88273 NCCI

81325 88274 NCCI

81325 88275 NCCI

81325 88291 NCCI

81325 88364 NCCI

81325 88365 NCCI

81325 88366 NCCI

81325 88367 NCCI

81325 88368 NCCI

81325 88369 NCCI

81325 88373 NCCI

Comprehensive ComponentCode Code Source

81325 88374 NCCI

81325 88377 NCCI

81325 G0476 NCCI

81326 80500 NCCI

81326 80502 NCCI

81326 84311 NCCI

81326 87140 NCCI

81326 87143 NCCI

81326 87147 NCCI

81326 87149 NCCI

81326 87150 NCCI

81326 87152 NCCI

81326 87153 NCCI

81326 87158 NCCI

81326 87470 NCCI

81326 87471 NCCI

81326 87472 NCCI

81326 87475 NCCI

81326 87476 NCCI

81326 87477 NCCI

81326 87480 NCCI

81326 87481 NCCI

81326 87482 NCCI

81326 87483 NCCI

81326 87485 NCCI

81326 87486 NCCI

81326 87487 NCCI

81326 87490 NCCI

81326 87491 NCCI

81326 87492 NCCI

81326 87493 NCCI

81326 87495 NCCI

81326 87496 NCCI

81326 87497 NCCI

81326 87498 NCCI

81326 87500 NCCI

81326 87501 NCCI

81326 87502 NCCI

81326 87503 NCCI

81326 87505 NCCI

81326 87506 NCCI

81326 87507 NCCI

81326 87510 NCCI

81326 87511 NCCI

81326 87512 NCCI

81326 87515 NCCI

81326 87516 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 122 of 255

Page 123: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81326 87517 NCCI

81326 87520 NCCI

81326 87521 NCCI

81326 87522 NCCI

81326 87525 NCCI

81326 87526 NCCI

81326 87527 NCCI

81326 87528 NCCI

81326 87529 NCCI

81326 87530 NCCI

81326 87531 NCCI

81326 87532 NCCI

81326 87533 NCCI

81326 87534 NCCI

81326 87535 NCCI

81326 87536 NCCI

81326 87537 NCCI

81326 87538 NCCI

81326 87539 NCCI

81326 87540 NCCI

81326 87541 NCCI

81326 87542 NCCI

81326 87550 NCCI

81326 87551 NCCI

81326 87552 NCCI

81326 87555 NCCI

81326 87556 NCCI

81326 87557 NCCI

81326 87560 NCCI

81326 87561 NCCI

81326 87562 NCCI

81326 87580 NCCI

81326 87581 NCCI

81326 87582 NCCI

81326 87590 NCCI

81326 87591 NCCI

81326 87592 NCCI

81326 87623 NCCI

81326 87624 NCCI

81326 87625 NCCI

81326 87631 NCCI

81326 87632 NCCI

81326 87633 NCCI

81326 87640 NCCI

81326 87641 NCCI

81326 87650 NCCI

81326 87651 NCCI

Comprehensive ComponentCode Code Source

81326 87652 NCCI

81326 87653 NCCI

81326 87660 NCCI

81326 87661 NCCI

81326 87797 NCCI

81326 87798 NCCI

81326 87799 NCCI

81326 87800 NCCI

81326 87801 NCCI

81326 88271 NCCI

81326 88272 NCCI

81326 88273 NCCI

81326 88274 NCCI

81326 88275 NCCI

81326 88291 NCCI

81326 88364 NCCI

81326 88365 NCCI

81326 88366 NCCI

81326 88367 NCCI

81326 88368 NCCI

81326 88369 NCCI

81326 88373 NCCI

81326 88374 NCCI

81326 88377 NCCI

81326 G0476 NCCI

81327 80500 NCCI

81327 80502 NCCI

81327 84311 NCCI

81327 87140 NCCI

81327 87143 NCCI

81327 87147 NCCI

81327 87149 NCCI

81327 87150 NCCI

81327 87152 NCCI

81327 87153 NCCI

81327 87158 NCCI

81327 87470 NCCI

81327 87471 NCCI

81327 87472 NCCI

81327 87475 NCCI

81327 87476 NCCI

81327 87477 NCCI

81327 87480 NCCI

81327 87481 NCCI

81327 87482 NCCI

81327 87483 NCCI

81327 87485 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 123 of 255

Page 124: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81327 87486 NCCI

81327 87487 NCCI

81327 87490 NCCI

81327 87491 NCCI

81327 87492 NCCI

81327 87493 NCCI

81327 87495 NCCI

81327 87496 NCCI

81327 87497 NCCI

81327 87498 NCCI

81327 87500 NCCI

81327 87501 NCCI

81327 87502 NCCI

81327 87503 NCCI

81327 87505 NCCI

81327 87506 NCCI

81327 87507 NCCI

81327 87510 NCCI

81327 87511 NCCI

81327 87512 NCCI

81327 87515 NCCI

81327 87516 NCCI

81327 87517 NCCI

81327 87520 NCCI

81327 87521 NCCI

81327 87522 NCCI

81327 87525 NCCI

81327 87526 NCCI

81327 87527 NCCI

81327 87528 NCCI

81327 87529 NCCI

81327 87530 NCCI

81327 87531 NCCI

81327 87532 NCCI

81327 87533 NCCI

81327 87534 NCCI

81327 87535 NCCI

81327 87536 NCCI

81327 87537 NCCI

81327 87538 NCCI

81327 87539 NCCI

81327 87540 NCCI

81327 87541 NCCI

81327 87542 NCCI

81327 87550 NCCI

81327 87551 NCCI

81327 87552 NCCI

Comprehensive ComponentCode Code Source

81327 87555 NCCI

81327 87556 NCCI

81327 87557 NCCI

81327 87560 NCCI

81327 87561 NCCI

81327 87562 NCCI

81327 87580 NCCI

81327 87581 NCCI

81327 87582 NCCI

81327 87590 NCCI

81327 87591 NCCI

81327 87592 NCCI

81327 87623 NCCI

81327 87624 NCCI

81327 87625 NCCI

81327 87631 NCCI

81327 87632 NCCI

81327 87633 NCCI

81327 87640 NCCI

81327 87641 NCCI

81327 87650 NCCI

81327 87651 NCCI

81327 87652 NCCI

81327 87653 NCCI

81327 87660 NCCI

81327 87661 NCCI

81327 87797 NCCI

81327 87798 NCCI

81327 87799 NCCI

81327 87800 NCCI

81327 87801 NCCI

81327 88271 NCCI

81327 88272 NCCI

81327 88273 NCCI

81327 88274 NCCI

81327 88275 NCCI

81327 88291 NCCI

81327 88364 NCCI

81327 88365 NCCI

81327 88366 NCCI

81327 88367 NCCI

81327 88368 NCCI

81327 88369 NCCI

81327 88373 NCCI

81327 88374 NCCI

81327 88377 NCCI

81327 96523 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 124 of 255

Page 125: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81327 G0476 NCCI

81330 80500 NCCI

81330 80502 NCCI

81330 84311 NCCI

81330 87140 NCCI

81330 87143 NCCI

81330 87147 NCCI

81330 87149 NCCI

81330 87150 NCCI

81330 87152 NCCI

81330 87153 NCCI

81330 87158 NCCI

81330 87470 NCCI

81330 87471 NCCI

81330 87472 NCCI

81330 87475 NCCI

81330 87476 NCCI

81330 87477 NCCI

81330 87480 NCCI

81330 87481 NCCI

81330 87482 NCCI

81330 87483 NCCI

81330 87485 NCCI

81330 87486 NCCI

81330 87487 NCCI

81330 87490 NCCI

81330 87491 NCCI

81330 87492 NCCI

81330 87493 NCCI

81330 87495 NCCI

81330 87496 NCCI

81330 87497 NCCI

81330 87498 NCCI

81330 87500 NCCI

81330 87501 NCCI

81330 87502 NCCI

81330 87503 NCCI

81330 87505 NCCI

81330 87506 NCCI

81330 87507 NCCI

81330 87510 NCCI

81330 87511 NCCI

81330 87512 NCCI

81330 87515 NCCI

81330 87516 NCCI

81330 87517 NCCI

81330 87520 NCCI

Comprehensive ComponentCode Code Source

81330 87521 NCCI

81330 87522 NCCI

81330 87525 NCCI

81330 87526 NCCI

81330 87527 NCCI

81330 87528 NCCI

81330 87529 NCCI

81330 87530 NCCI

81330 87531 NCCI

81330 87532 NCCI

81330 87533 NCCI

81330 87534 NCCI

81330 87535 NCCI

81330 87536 NCCI

81330 87537 NCCI

81330 87538 NCCI

81330 87539 NCCI

81330 87540 NCCI

81330 87541 NCCI

81330 87542 NCCI

81330 87550 NCCI

81330 87551 NCCI

81330 87552 NCCI

81330 87555 NCCI

81330 87556 NCCI

81330 87557 NCCI

81330 87560 NCCI

81330 87561 NCCI

81330 87562 NCCI

81330 87580 NCCI

81330 87581 NCCI

81330 87582 NCCI

81330 87590 NCCI

81330 87591 NCCI

81330 87592 NCCI

81330 87623 NCCI

81330 87624 NCCI

81330 87625 NCCI

81330 87631 NCCI

81330 87632 NCCI

81330 87633 NCCI

81330 87640 NCCI

81330 87641 NCCI

81330 87650 NCCI

81330 87651 NCCI

81330 87652 NCCI

81330 87653 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 125 of 255

Page 126: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81330 87660 NCCI

81330 87661 NCCI

81330 87797 NCCI

81330 87798 NCCI

81330 87799 NCCI

81330 87800 NCCI

81330 87801 NCCI

81330 88271 NCCI

81330 88272 NCCI

81330 88273 NCCI

81330 88274 NCCI

81330 88275 NCCI

81330 88291 NCCI

81330 88364 NCCI

81330 88365 NCCI

81330 88366 NCCI

81330 88367 NCCI

81330 88368 NCCI

81330 88369 NCCI

81330 88373 NCCI

81330 88374 NCCI

81330 88377 NCCI

81330 G0476 NCCI

81331 80500 NCCI

81331 80502 NCCI

81331 84311 NCCI

81331 87140 NCCI

81331 87143 NCCI

81331 87147 NCCI

81331 87149 NCCI

81331 87150 NCCI

81331 87152 NCCI

81331 87153 NCCI

81331 87158 NCCI

81331 87470 NCCI

81331 87471 NCCI

81331 87472 NCCI

81331 87475 NCCI

81331 87476 NCCI

81331 87477 NCCI

81331 87480 NCCI

81331 87481 NCCI

81331 87482 NCCI

81331 87483 NCCI

81331 87485 NCCI

81331 87486 NCCI

81331 87487 NCCI

Comprehensive ComponentCode Code Source

81331 87490 NCCI

81331 87491 NCCI

81331 87492 NCCI

81331 87493 NCCI

81331 87495 NCCI

81331 87496 NCCI

81331 87497 NCCI

81331 87498 NCCI

81331 87500 NCCI

81331 87501 NCCI

81331 87502 NCCI

81331 87503 NCCI

81331 87505 NCCI

81331 87506 NCCI

81331 87507 NCCI

81331 87510 NCCI

81331 87511 NCCI

81331 87512 NCCI

81331 87515 NCCI

81331 87516 NCCI

81331 87517 NCCI

81331 87520 NCCI

81331 87521 NCCI

81331 87522 NCCI

81331 87525 NCCI

81331 87526 NCCI

81331 87527 NCCI

81331 87528 NCCI

81331 87529 NCCI

81331 87530 NCCI

81331 87531 NCCI

81331 87532 NCCI

81331 87533 NCCI

81331 87534 NCCI

81331 87535 NCCI

81331 87536 NCCI

81331 87537 NCCI

81331 87538 NCCI

81331 87539 NCCI

81331 87540 NCCI

81331 87541 NCCI

81331 87542 NCCI

81331 87550 NCCI

81331 87551 NCCI

81331 87552 NCCI

81331 87555 NCCI

81331 87556 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 126 of 255

Page 127: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81331 87557 NCCI

81331 87560 NCCI

81331 87561 NCCI

81331 87562 NCCI

81331 87580 NCCI

81331 87581 NCCI

81331 87582 NCCI

81331 87590 NCCI

81331 87591 NCCI

81331 87592 NCCI

81331 87623 NCCI

81331 87624 NCCI

81331 87625 NCCI

81331 87631 NCCI

81331 87632 NCCI

81331 87633 NCCI

81331 87640 NCCI

81331 87641 NCCI

81331 87650 NCCI

81331 87651 NCCI

81331 87652 NCCI

81331 87653 NCCI

81331 87660 NCCI

81331 87661 NCCI

81331 87797 NCCI

81331 87798 NCCI

81331 87799 NCCI

81331 87800 NCCI

81331 87801 NCCI

81331 88271 NCCI

81331 88272 NCCI

81331 88273 NCCI

81331 88274 NCCI

81331 88275 NCCI

81331 88291 NCCI

81331 88364 NCCI

81331 88365 NCCI

81331 88366 NCCI

81331 88367 NCCI

81331 88368 NCCI

81331 88369 NCCI

81331 88373 NCCI

81331 88374 NCCI

81331 88377 NCCI

81331 G0476 NCCI

81332 80500 NCCI

81332 80502 NCCI

Comprehensive ComponentCode Code Source

81332 84311 NCCI

81332 87140 NCCI

81332 87143 NCCI

81332 87147 NCCI

81332 87149 NCCI

81332 87150 NCCI

81332 87152 NCCI

81332 87153 NCCI

81332 87158 NCCI

81332 87470 NCCI

81332 87471 NCCI

81332 87472 NCCI

81332 87475 NCCI

81332 87476 NCCI

81332 87477 NCCI

81332 87480 NCCI

81332 87481 NCCI

81332 87482 NCCI

81332 87483 NCCI

81332 87485 NCCI

81332 87486 NCCI

81332 87487 NCCI

81332 87490 NCCI

81332 87491 NCCI

81332 87492 NCCI

81332 87493 NCCI

81332 87495 NCCI

81332 87496 NCCI

81332 87497 NCCI

81332 87498 NCCI

81332 87500 NCCI

81332 87501 NCCI

81332 87502 NCCI

81332 87503 NCCI

81332 87505 NCCI

81332 87506 NCCI

81332 87507 NCCI

81332 87510 NCCI

81332 87511 NCCI

81332 87512 NCCI

81332 87515 NCCI

81332 87516 NCCI

81332 87517 NCCI

81332 87520 NCCI

81332 87521 NCCI

81332 87522 NCCI

81332 87525 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 127 of 255

Page 128: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81332 87526 NCCI

81332 87527 NCCI

81332 87528 NCCI

81332 87529 NCCI

81332 87530 NCCI

81332 87531 NCCI

81332 87532 NCCI

81332 87533 NCCI

81332 87534 NCCI

81332 87535 NCCI

81332 87536 NCCI

81332 87537 NCCI

81332 87538 NCCI

81332 87539 NCCI

81332 87540 NCCI

81332 87541 NCCI

81332 87542 NCCI

81332 87550 NCCI

81332 87551 NCCI

81332 87552 NCCI

81332 87555 NCCI

81332 87556 NCCI

81332 87557 NCCI

81332 87560 NCCI

81332 87561 NCCI

81332 87562 NCCI

81332 87580 NCCI

81332 87581 NCCI

81332 87582 NCCI

81332 87590 NCCI

81332 87591 NCCI

81332 87592 NCCI

81332 87623 NCCI

81332 87624 NCCI

81332 87625 NCCI

81332 87631 NCCI

81332 87632 NCCI

81332 87633 NCCI

81332 87640 NCCI

81332 87641 NCCI

81332 87650 NCCI

81332 87651 NCCI

81332 87652 NCCI

81332 87653 NCCI

81332 87660 NCCI

81332 87661 NCCI

81332 87797 NCCI

Comprehensive ComponentCode Code Source

81332 87798 NCCI

81332 87799 NCCI

81332 87800 NCCI

81332 87801 NCCI

81332 88271 NCCI

81332 88272 NCCI

81332 88273 NCCI

81332 88274 NCCI

81332 88275 NCCI

81332 88291 NCCI

81332 88364 NCCI

81332 88365 NCCI

81332 88366 NCCI

81332 88367 NCCI

81332 88368 NCCI

81332 88369 NCCI

81332 88373 NCCI

81332 88374 NCCI

81332 88377 NCCI

81332 G0476 NCCI

81340 80500 NCCI

81340 80502 NCCI

81340 81341 NCCI

81340 84311 NCCI

81340 87140 NCCI

81340 87143 NCCI

81340 87147 NCCI

81340 87149 NCCI

81340 87150 NCCI

81340 87152 NCCI

81340 87153 NCCI

81340 87158 NCCI

81340 87470 NCCI

81340 87471 NCCI

81340 87472 NCCI

81340 87475 NCCI

81340 87476 NCCI

81340 87477 NCCI

81340 87480 NCCI

81340 87481 NCCI

81340 87482 NCCI

81340 87483 NCCI

81340 87485 NCCI

81340 87486 NCCI

81340 87487 NCCI

81340 87490 NCCI

81340 87491 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 128 of 255

Page 129: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81340 87492 NCCI

81340 87493 NCCI

81340 87495 NCCI

81340 87496 NCCI

81340 87497 NCCI

81340 87498 NCCI

81340 87500 NCCI

81340 87501 NCCI

81340 87502 NCCI

81340 87503 NCCI

81340 87505 NCCI

81340 87506 NCCI

81340 87507 NCCI

81340 87510 NCCI

81340 87511 NCCI

81340 87512 NCCI

81340 87515 NCCI

81340 87516 NCCI

81340 87517 NCCI

81340 87520 NCCI

81340 87521 NCCI

81340 87522 NCCI

81340 87525 NCCI

81340 87526 NCCI

81340 87527 NCCI

81340 87528 NCCI

81340 87529 NCCI

81340 87530 NCCI

81340 87531 NCCI

81340 87532 NCCI

81340 87533 NCCI

81340 87534 NCCI

81340 87535 NCCI

81340 87536 NCCI

81340 87537 NCCI

81340 87538 NCCI

81340 87539 NCCI

81340 87540 NCCI

81340 87541 NCCI

81340 87542 NCCI

81340 87550 NCCI

81340 87551 NCCI

81340 87552 NCCI

81340 87555 NCCI

81340 87556 NCCI

81340 87557 NCCI

81340 87560 NCCI

Comprehensive ComponentCode Code Source

81340 87561 NCCI

81340 87562 NCCI

81340 87580 NCCI

81340 87581 NCCI

81340 87582 NCCI

81340 87590 NCCI

81340 87591 NCCI

81340 87592 NCCI

81340 87623 NCCI

81340 87624 NCCI

81340 87625 NCCI

81340 87631 NCCI

81340 87632 NCCI

81340 87633 NCCI

81340 87640 NCCI

81340 87641 NCCI

81340 87650 NCCI

81340 87651 NCCI

81340 87652 NCCI

81340 87653 NCCI

81340 87660 NCCI

81340 87661 NCCI

81340 87797 NCCI

81340 87798 NCCI

81340 87799 NCCI

81340 87800 NCCI

81340 87801 NCCI

81340 88271 NCCI

81340 88272 NCCI

81340 88273 NCCI

81340 88274 NCCI

81340 88275 NCCI

81340 88291 NCCI

81340 88364 NCCI

81340 88365 NCCI

81340 88366 NCCI

81340 88367 NCCI

81340 88368 NCCI

81340 88369 NCCI

81340 88373 NCCI

81340 88374 NCCI

81340 88377 NCCI

81340 G0476 NCCI

81341 80500 NCCI

81341 80502 NCCI

81341 84311 NCCI

81341 87140 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 129 of 255

Page 130: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81341 87143 NCCI

81341 87147 NCCI

81341 87149 NCCI

81341 87150 NCCI

81341 87152 NCCI

81341 87153 NCCI

81341 87158 NCCI

81341 87470 NCCI

81341 87471 NCCI

81341 87472 NCCI

81341 87475 NCCI

81341 87476 NCCI

81341 87477 NCCI

81341 87480 NCCI

81341 87481 NCCI

81341 87482 NCCI

81341 87483 NCCI

81341 87485 NCCI

81341 87486 NCCI

81341 87487 NCCI

81341 87490 NCCI

81341 87491 NCCI

81341 87492 NCCI

81341 87493 NCCI

81341 87495 NCCI

81341 87496 NCCI

81341 87497 NCCI

81341 87498 NCCI

81341 87500 NCCI

81341 87501 NCCI

81341 87502 NCCI

81341 87503 NCCI

81341 87505 NCCI

81341 87506 NCCI

81341 87507 NCCI

81341 87510 NCCI

81341 87511 NCCI

81341 87512 NCCI

81341 87515 NCCI

81341 87516 NCCI

81341 87517 NCCI

81341 87520 NCCI

81341 87521 NCCI

81341 87522 NCCI

81341 87525 NCCI

81341 87526 NCCI

81341 87527 NCCI

Comprehensive ComponentCode Code Source

81341 87528 NCCI

81341 87529 NCCI

81341 87530 NCCI

81341 87531 NCCI

81341 87532 NCCI

81341 87533 NCCI

81341 87534 NCCI

81341 87535 NCCI

81341 87536 NCCI

81341 87537 NCCI

81341 87538 NCCI

81341 87539 NCCI

81341 87540 NCCI

81341 87541 NCCI

81341 87542 NCCI

81341 87550 NCCI

81341 87551 NCCI

81341 87552 NCCI

81341 87555 NCCI

81341 87556 NCCI

81341 87557 NCCI

81341 87560 NCCI

81341 87561 NCCI

81341 87562 NCCI

81341 87580 NCCI

81341 87581 NCCI

81341 87582 NCCI

81341 87590 NCCI

81341 87591 NCCI

81341 87592 NCCI

81341 87623 NCCI

81341 87624 NCCI

81341 87625 NCCI

81341 87631 NCCI

81341 87632 NCCI

81341 87633 NCCI

81341 87640 NCCI

81341 87641 NCCI

81341 87650 NCCI

81341 87651 NCCI

81341 87652 NCCI

81341 87653 NCCI

81341 87660 NCCI

81341 87661 NCCI

81341 87797 NCCI

81341 87798 NCCI

81341 87799 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 130 of 255

Page 131: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81341 87800 NCCI

81341 87801 NCCI

81341 88271 NCCI

81341 88272 NCCI

81341 88273 NCCI

81341 88274 NCCI

81341 88275 NCCI

81341 88291 NCCI

81341 88364 NCCI

81341 88365 NCCI

81341 88366 NCCI

81341 88367 NCCI

81341 88368 NCCI

81341 88369 NCCI

81341 88373 NCCI

81341 88374 NCCI

81341 88377 NCCI

81341 G0476 NCCI

81342 80500 NCCI

81342 80502 NCCI

81342 84311 NCCI

81342 87140 NCCI

81342 87143 NCCI

81342 87147 NCCI

81342 87149 NCCI

81342 87150 NCCI

81342 87152 NCCI

81342 87153 NCCI

81342 87158 NCCI

81342 87470 NCCI

81342 87471 NCCI

81342 87472 NCCI

81342 87475 NCCI

81342 87476 NCCI

81342 87477 NCCI

81342 87480 NCCI

81342 87481 NCCI

81342 87482 NCCI

81342 87483 NCCI

81342 87485 NCCI

81342 87486 NCCI

81342 87487 NCCI

81342 87490 NCCI

81342 87491 NCCI

81342 87492 NCCI

81342 87493 NCCI

81342 87495 NCCI

Comprehensive ComponentCode Code Source

81342 87496 NCCI

81342 87497 NCCI

81342 87498 NCCI

81342 87500 NCCI

81342 87501 NCCI

81342 87502 NCCI

81342 87503 NCCI

81342 87505 NCCI

81342 87506 NCCI

81342 87507 NCCI

81342 87510 NCCI

81342 87511 NCCI

81342 87512 NCCI

81342 87515 NCCI

81342 87516 NCCI

81342 87517 NCCI

81342 87520 NCCI

81342 87521 NCCI

81342 87522 NCCI

81342 87525 NCCI

81342 87526 NCCI

81342 87527 NCCI

81342 87528 NCCI

81342 87529 NCCI

81342 87530 NCCI

81342 87531 NCCI

81342 87532 NCCI

81342 87533 NCCI

81342 87534 NCCI

81342 87535 NCCI

81342 87536 NCCI

81342 87537 NCCI

81342 87538 NCCI

81342 87539 NCCI

81342 87540 NCCI

81342 87541 NCCI

81342 87542 NCCI

81342 87550 NCCI

81342 87551 NCCI

81342 87552 NCCI

81342 87555 NCCI

81342 87556 NCCI

81342 87557 NCCI

81342 87560 NCCI

81342 87561 NCCI

81342 87562 NCCI

81342 87580 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 131 of 255

Page 132: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81342 87581 NCCI

81342 87582 NCCI

81342 87590 NCCI

81342 87591 NCCI

81342 87592 NCCI

81342 87623 NCCI

81342 87624 NCCI

81342 87625 NCCI

81342 87631 NCCI

81342 87632 NCCI

81342 87633 NCCI

81342 87640 NCCI

81342 87641 NCCI

81342 87650 NCCI

81342 87651 NCCI

81342 87652 NCCI

81342 87653 NCCI

81342 87660 NCCI

81342 87661 NCCI

81342 87797 NCCI

81342 87798 NCCI

81342 87799 NCCI

81342 87800 NCCI

81342 87801 NCCI

81342 88271 NCCI

81342 88272 NCCI

81342 88273 NCCI

81342 88274 NCCI

81342 88275 NCCI

81342 88291 NCCI

81342 88364 NCCI

81342 88365 NCCI

81342 88366 NCCI

81342 88367 NCCI

81342 88368 NCCI

81342 88369 NCCI

81342 88373 NCCI

81342 88374 NCCI

81342 88377 NCCI

81342 G0476 NCCI

81350 80500 NCCI

81350 80502 NCCI

81350 84311 NCCI

81350 87140 NCCI

81350 87143 NCCI

81350 87147 NCCI

81350 87149 NCCI

Comprehensive ComponentCode Code Source

81350 87150 NCCI

81350 87152 NCCI

81350 87153 NCCI

81350 87158 NCCI

81350 87470 NCCI

81350 87471 NCCI

81350 87472 NCCI

81350 87475 NCCI

81350 87476 NCCI

81350 87477 NCCI

81350 87480 NCCI

81350 87481 NCCI

81350 87482 NCCI

81350 87483 NCCI

81350 87485 NCCI

81350 87486 NCCI

81350 87487 NCCI

81350 87490 NCCI

81350 87491 NCCI

81350 87492 NCCI

81350 87493 NCCI

81350 87495 NCCI

81350 87496 NCCI

81350 87497 NCCI

81350 87498 NCCI

81350 87500 NCCI

81350 87501 NCCI

81350 87502 NCCI

81350 87503 NCCI

81350 87505 NCCI

81350 87506 NCCI

81350 87507 NCCI

81350 87510 NCCI

81350 87511 NCCI

81350 87512 NCCI

81350 87515 NCCI

81350 87516 NCCI

81350 87517 NCCI

81350 87520 NCCI

81350 87521 NCCI

81350 87522 NCCI

81350 87525 NCCI

81350 87526 NCCI

81350 87527 NCCI

81350 87528 NCCI

81350 87529 NCCI

81350 87530 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 132 of 255

Page 133: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81350 87531 NCCI

81350 87532 NCCI

81350 87533 NCCI

81350 87534 NCCI

81350 87535 NCCI

81350 87536 NCCI

81350 87537 NCCI

81350 87538 NCCI

81350 87539 NCCI

81350 87540 NCCI

81350 87541 NCCI

81350 87542 NCCI

81350 87550 NCCI

81350 87551 NCCI

81350 87552 NCCI

81350 87555 NCCI

81350 87556 NCCI

81350 87557 NCCI

81350 87560 NCCI

81350 87561 NCCI

81350 87562 NCCI

81350 87580 NCCI

81350 87581 NCCI

81350 87582 NCCI

81350 87590 NCCI

81350 87591 NCCI

81350 87592 NCCI

81350 87623 NCCI

81350 87624 NCCI

81350 87625 NCCI

81350 87631 NCCI

81350 87632 NCCI

81350 87633 NCCI

81350 87640 NCCI

81350 87641 NCCI

81350 87650 NCCI

81350 87651 NCCI

81350 87652 NCCI

81350 87653 NCCI

81350 87660 NCCI

81350 87661 NCCI

81350 87797 NCCI

81350 87798 NCCI

81350 87799 NCCI

81350 87800 NCCI

81350 87801 NCCI

81350 88271 NCCI

Comprehensive ComponentCode Code Source

81350 88272 NCCI

81350 88273 NCCI

81350 88274 NCCI

81350 88275 NCCI

81350 88291 NCCI

81350 88364 NCCI

81350 88365 NCCI

81350 88366 NCCI

81350 88367 NCCI

81350 88368 NCCI

81350 88369 NCCI

81350 88373 NCCI

81350 88374 NCCI

81350 88377 NCCI

81350 G0476 NCCI

81355 80500 NCCI

81355 80502 NCCI

81355 84311 NCCI

81355 87140 NCCI

81355 87143 NCCI

81355 87147 NCCI

81355 87149 NCCI

81355 87150 NCCI

81355 87152 NCCI

81355 87153 NCCI

81355 87158 NCCI

81355 87470 NCCI

81355 87471 NCCI

81355 87472 NCCI

81355 87475 NCCI

81355 87476 NCCI

81355 87477 NCCI

81355 87480 NCCI

81355 87481 NCCI

81355 87482 NCCI

81355 87483 NCCI

81355 87485 NCCI

81355 87486 NCCI

81355 87487 NCCI

81355 87490 NCCI

81355 87491 NCCI

81355 87492 NCCI

81355 87493 NCCI

81355 87495 NCCI

81355 87496 NCCI

81355 87497 NCCI

81355 87498 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 133 of 255

Page 134: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81355 87500 NCCI

81355 87501 NCCI

81355 87502 NCCI

81355 87503 NCCI

81355 87505 NCCI

81355 87506 NCCI

81355 87507 NCCI

81355 87510 NCCI

81355 87511 NCCI

81355 87512 NCCI

81355 87515 NCCI

81355 87516 NCCI

81355 87517 NCCI

81355 87520 NCCI

81355 87521 NCCI

81355 87522 NCCI

81355 87525 NCCI

81355 87526 NCCI

81355 87527 NCCI

81355 87528 NCCI

81355 87529 NCCI

81355 87530 NCCI

81355 87531 NCCI

81355 87532 NCCI

81355 87533 NCCI

81355 87534 NCCI

81355 87535 NCCI

81355 87536 NCCI

81355 87537 NCCI

81355 87538 NCCI

81355 87539 NCCI

81355 87540 NCCI

81355 87541 NCCI

81355 87542 NCCI

81355 87550 NCCI

81355 87551 NCCI

81355 87552 NCCI

81355 87555 NCCI

81355 87556 NCCI

81355 87557 NCCI

81355 87560 NCCI

81355 87561 NCCI

81355 87562 NCCI

81355 87580 NCCI

81355 87581 NCCI

81355 87582 NCCI

81355 87590 NCCI

Comprehensive ComponentCode Code Source

81355 87591 NCCI

81355 87592 NCCI

81355 87623 NCCI

81355 87624 NCCI

81355 87625 NCCI

81355 87631 NCCI

81355 87632 NCCI

81355 87633 NCCI

81355 87640 NCCI

81355 87641 NCCI

81355 87650 NCCI

81355 87651 NCCI

81355 87652 NCCI

81355 87653 NCCI

81355 87660 NCCI

81355 87661 NCCI

81355 87797 NCCI

81355 87798 NCCI

81355 87799 NCCI

81355 87800 NCCI

81355 87801 NCCI

81355 88271 NCCI

81355 88272 NCCI

81355 88273 NCCI

81355 88274 NCCI

81355 88275 NCCI

81355 88291 NCCI

81355 88364 NCCI

81355 88365 NCCI

81355 88366 NCCI

81355 88367 NCCI

81355 88368 NCCI

81355 88369 NCCI

81355 88373 NCCI

81355 88374 NCCI

81355 88377 NCCI

81355 G0476 NCCI

81370 80500 NCCI

81370 80502 NCCI

81370 81371 NCCI

81370 81372 NCCI

81370 81373 NCCI

81370 81374 NCCI

81370 81375 NCCI

81370 81376 NCCI

81370 81377 NCCI

81370 84311 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 134 of 255

Page 135: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81370 86812 NCCI

81370 86813 NCCI

81370 86816 NCCI

81370 86817 NCCI

81370 87140 NCCI

81370 87143 NCCI

81370 87147 NCCI

81370 87149 NCCI

81370 87150 NCCI

81370 87152 NCCI

81370 87153 NCCI

81370 87158 NCCI

81370 87470 NCCI

81370 87471 NCCI

81370 87472 NCCI

81370 87475 NCCI

81370 87476 NCCI

81370 87477 NCCI

81370 87480 NCCI

81370 87481 NCCI

81370 87482 NCCI

81370 87483 NCCI

81370 87485 NCCI

81370 87486 NCCI

81370 87487 NCCI

81370 87490 NCCI

81370 87491 NCCI

81370 87492 NCCI

81370 87493 NCCI

81370 87495 NCCI

81370 87496 NCCI

81370 87497 NCCI

81370 87498 NCCI

81370 87500 NCCI

81370 87501 NCCI

81370 87502 NCCI

81370 87503 NCCI

81370 87505 NCCI

81370 87506 NCCI

81370 87507 NCCI

81370 87510 NCCI

81370 87511 NCCI

81370 87512 NCCI

81370 87515 NCCI

81370 87516 NCCI

81370 87517 NCCI

81370 87520 NCCI

Comprehensive ComponentCode Code Source

81370 87521 NCCI

81370 87522 NCCI

81370 87525 NCCI

81370 87526 NCCI

81370 87527 NCCI

81370 87528 NCCI

81370 87529 NCCI

81370 87530 NCCI

81370 87531 NCCI

81370 87532 NCCI

81370 87533 NCCI

81370 87534 NCCI

81370 87535 NCCI

81370 87536 NCCI

81370 87537 NCCI

81370 87538 NCCI

81370 87539 NCCI

81370 87540 NCCI

81370 87541 NCCI

81370 87542 NCCI

81370 87550 NCCI

81370 87551 NCCI

81370 87552 NCCI

81370 87555 NCCI

81370 87556 NCCI

81370 87557 NCCI

81370 87560 NCCI

81370 87561 NCCI

81370 87562 NCCI

81370 87580 NCCI

81370 87581 NCCI

81370 87582 NCCI

81370 87590 NCCI

81370 87591 NCCI

81370 87592 NCCI

81370 87623 NCCI

81370 87624 NCCI

81370 87625 NCCI

81370 87631 NCCI

81370 87632 NCCI

81370 87633 NCCI

81370 87640 NCCI

81370 87641 NCCI

81370 87650 NCCI

81370 87651 NCCI

81370 87652 NCCI

81370 87653 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 135 of 255

Page 136: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81370 87660 NCCI

81370 87661 NCCI

81370 87797 NCCI

81370 87798 NCCI

81370 87799 NCCI

81370 87800 NCCI

81370 87801 NCCI

81370 88291 NCCI

81370 G0476 NCCI

81371 80500 NCCI

81371 80502 NCCI

81371 81372 NCCI

81371 81373 NCCI

81371 81374 NCCI

81371 81375 NCCI

81371 81376 NCCI

81371 81377 NCCI

81371 84311 NCCI

81371 86812 NCCI

81371 86813 NCCI

81371 86816 NCCI

81371 86817 NCCI

81371 87140 NCCI

81371 87143 NCCI

81371 87147 NCCI

81371 87149 NCCI

81371 87150 NCCI

81371 87152 NCCI

81371 87153 NCCI

81371 87158 NCCI

81371 87470 NCCI

81371 87471 NCCI

81371 87472 NCCI

81371 87475 NCCI

81371 87476 NCCI

81371 87477 NCCI

81371 87480 NCCI

81371 87481 NCCI

81371 87482 NCCI

81371 87483 NCCI

81371 87485 NCCI

81371 87486 NCCI

81371 87487 NCCI

81371 87490 NCCI

81371 87491 NCCI

81371 87492 NCCI

81371 87493 NCCI

Comprehensive ComponentCode Code Source

81371 87495 NCCI

81371 87496 NCCI

81371 87497 NCCI

81371 87498 NCCI

81371 87500 NCCI

81371 87501 NCCI

81371 87502 NCCI

81371 87503 NCCI

81371 87505 NCCI

81371 87506 NCCI

81371 87507 NCCI

81371 87510 NCCI

81371 87511 NCCI

81371 87512 NCCI

81371 87515 NCCI

81371 87516 NCCI

81371 87517 NCCI

81371 87520 NCCI

81371 87521 NCCI

81371 87522 NCCI

81371 87525 NCCI

81371 87526 NCCI

81371 87527 NCCI

81371 87528 NCCI

81371 87529 NCCI

81371 87530 NCCI

81371 87531 NCCI

81371 87532 NCCI

81371 87533 NCCI

81371 87534 NCCI

81371 87535 NCCI

81371 87536 NCCI

81371 87537 NCCI

81371 87538 NCCI

81371 87539 NCCI

81371 87540 NCCI

81371 87541 NCCI

81371 87542 NCCI

81371 87550 NCCI

81371 87551 NCCI

81371 87552 NCCI

81371 87555 NCCI

81371 87556 NCCI

81371 87557 NCCI

81371 87560 NCCI

81371 87561 NCCI

81371 87562 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 136 of 255

Page 137: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81371 87580 NCCI

81371 87581 NCCI

81371 87582 NCCI

81371 87590 NCCI

81371 87591 NCCI

81371 87592 NCCI

81371 87623 NCCI

81371 87624 NCCI

81371 87625 NCCI

81371 87631 NCCI

81371 87632 NCCI

81371 87633 NCCI

81371 87640 NCCI

81371 87641 NCCI

81371 87650 NCCI

81371 87651 NCCI

81371 87652 NCCI

81371 87653 NCCI

81371 87660 NCCI

81371 87661 NCCI

81371 87797 NCCI

81371 87798 NCCI

81371 87799 NCCI

81371 87800 NCCI

81371 87801 NCCI

81371 88291 NCCI

81371 G0476 NCCI

81372 80500 NCCI

81372 80502 NCCI

81372 81373 NCCI

81372 81374 NCCI

81372 81375 NCCI

81372 81376 NCCI

81372 84311 NCCI

81372 86812 NCCI

81372 86813 NCCI

81372 86816 NCCI

81372 87140 NCCI

81372 87143 NCCI

81372 87147 NCCI

81372 87149 NCCI

81372 87150 NCCI

81372 87152 NCCI

81372 87153 NCCI

81372 87158 NCCI

81372 87470 NCCI

81372 87471 NCCI

Comprehensive ComponentCode Code Source

81372 87472 NCCI

81372 87475 NCCI

81372 87476 NCCI

81372 87477 NCCI

81372 87480 NCCI

81372 87481 NCCI

81372 87482 NCCI

81372 87483 NCCI

81372 87485 NCCI

81372 87486 NCCI

81372 87487 NCCI

81372 87490 NCCI

81372 87491 NCCI

81372 87492 NCCI

81372 87493 NCCI

81372 87495 NCCI

81372 87496 NCCI

81372 87497 NCCI

81372 87498 NCCI

81372 87500 NCCI

81372 87501 NCCI

81372 87502 NCCI

81372 87503 NCCI

81372 87505 NCCI

81372 87506 NCCI

81372 87507 NCCI

81372 87510 NCCI

81372 87511 NCCI

81372 87512 NCCI

81372 87515 NCCI

81372 87516 NCCI

81372 87517 NCCI

81372 87520 NCCI

81372 87521 NCCI

81372 87522 NCCI

81372 87525 NCCI

81372 87526 NCCI

81372 87527 NCCI

81372 87528 NCCI

81372 87529 NCCI

81372 87530 NCCI

81372 87531 NCCI

81372 87532 NCCI

81372 87533 NCCI

81372 87534 NCCI

81372 87535 NCCI

81372 87536 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 137 of 255

Page 138: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81372 87537 NCCI

81372 87538 NCCI

81372 87539 NCCI

81372 87540 NCCI

81372 87541 NCCI

81372 87542 NCCI

81372 87550 NCCI

81372 87551 NCCI

81372 87552 NCCI

81372 87555 NCCI

81372 87556 NCCI

81372 87557 NCCI

81372 87560 NCCI

81372 87561 NCCI

81372 87562 NCCI

81372 87580 NCCI

81372 87581 NCCI

81372 87582 NCCI

81372 87590 NCCI

81372 87591 NCCI

81372 87592 NCCI

81372 87623 NCCI

81372 87624 NCCI

81372 87625 NCCI

81372 87631 NCCI

81372 87632 NCCI

81372 87633 NCCI

81372 87640 NCCI

81372 87641 NCCI

81372 87650 NCCI

81372 87651 NCCI

81372 87652 NCCI

81372 87653 NCCI

81372 87660 NCCI

81372 87661 NCCI

81372 87797 NCCI

81372 87798 NCCI

81372 87799 NCCI

81372 87800 NCCI

81372 87801 NCCI

81372 88291 NCCI

81372 G0476 NCCI

81373 80500 NCCI

81373 80502 NCCI

81373 81374 NCCI

81373 81376 NCCI

81373 84311 NCCI

Comprehensive ComponentCode Code Source

81373 86812 NCCI

81373 86813 NCCI

81373 86816 NCCI

81373 86817 NCCI

81373 87140 NCCI

81373 87143 NCCI

81373 87147 NCCI

81373 87149 NCCI

81373 87150 NCCI

81373 87152 NCCI

81373 87153 NCCI

81373 87158 NCCI

81373 87470 NCCI

81373 87471 NCCI

81373 87472 NCCI

81373 87475 NCCI

81373 87476 NCCI

81373 87477 NCCI

81373 87480 NCCI

81373 87481 NCCI

81373 87482 NCCI

81373 87483 NCCI

81373 87485 NCCI

81373 87486 NCCI

81373 87487 NCCI

81373 87490 NCCI

81373 87491 NCCI

81373 87492 NCCI

81373 87493 NCCI

81373 87495 NCCI

81373 87496 NCCI

81373 87497 NCCI

81373 87498 NCCI

81373 87500 NCCI

81373 87501 NCCI

81373 87502 NCCI

81373 87503 NCCI

81373 87505 NCCI

81373 87506 NCCI

81373 87507 NCCI

81373 87510 NCCI

81373 87511 NCCI

81373 87512 NCCI

81373 87515 NCCI

81373 87516 NCCI

81373 87517 NCCI

81373 87520 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 138 of 255

Page 139: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81373 87521 NCCI

81373 87522 NCCI

81373 87525 NCCI

81373 87526 NCCI

81373 87527 NCCI

81373 87528 NCCI

81373 87529 NCCI

81373 87530 NCCI

81373 87531 NCCI

81373 87532 NCCI

81373 87533 NCCI

81373 87534 NCCI

81373 87535 NCCI

81373 87536 NCCI

81373 87537 NCCI

81373 87538 NCCI

81373 87539 NCCI

81373 87540 NCCI

81373 87541 NCCI

81373 87542 NCCI

81373 87550 NCCI

81373 87551 NCCI

81373 87552 NCCI

81373 87555 NCCI

81373 87556 NCCI

81373 87557 NCCI

81373 87560 NCCI

81373 87561 NCCI

81373 87562 NCCI

81373 87580 NCCI

81373 87581 NCCI

81373 87582 NCCI

81373 87590 NCCI

81373 87591 NCCI

81373 87592 NCCI

81373 87623 NCCI

81373 87624 NCCI

81373 87625 NCCI

81373 87631 NCCI

81373 87632 NCCI

81373 87633 NCCI

81373 87640 NCCI

81373 87641 NCCI

81373 87650 NCCI

81373 87651 NCCI

81373 87652 NCCI

81373 87653 NCCI

Comprehensive ComponentCode Code Source

81373 87660 NCCI

81373 87661 NCCI

81373 87797 NCCI

81373 87798 NCCI

81373 87799 NCCI

81373 87800 NCCI

81373 87801 NCCI

81373 88291 NCCI

81373 G0476 NCCI

81374 80500 NCCI

81374 80502 NCCI

81374 84311 NCCI

81374 86812 NCCI

81374 86813 NCCI

81374 87140 NCCI

81374 87143 NCCI

81374 87147 NCCI

81374 87149 NCCI

81374 87150 NCCI

81374 87152 NCCI

81374 87153 NCCI

81374 87158 NCCI

81374 87470 NCCI

81374 87471 NCCI

81374 87472 NCCI

81374 87475 NCCI

81374 87476 NCCI

81374 87477 NCCI

81374 87480 NCCI

81374 87481 NCCI

81374 87482 NCCI

81374 87483 NCCI

81374 87485 NCCI

81374 87486 NCCI

81374 87487 NCCI

81374 87490 NCCI

81374 87491 NCCI

81374 87492 NCCI

81374 87493 NCCI

81374 87495 NCCI

81374 87496 NCCI

81374 87497 NCCI

81374 87498 NCCI

81374 87500 NCCI

81374 87501 NCCI

81374 87502 NCCI

81374 87503 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 139 of 255

Page 140: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81374 87505 NCCI

81374 87506 NCCI

81374 87507 NCCI

81374 87510 NCCI

81374 87511 NCCI

81374 87512 NCCI

81374 87515 NCCI

81374 87516 NCCI

81374 87517 NCCI

81374 87520 NCCI

81374 87521 NCCI

81374 87522 NCCI

81374 87525 NCCI

81374 87526 NCCI

81374 87527 NCCI

81374 87528 NCCI

81374 87529 NCCI

81374 87530 NCCI

81374 87531 NCCI

81374 87532 NCCI

81374 87533 NCCI

81374 87534 NCCI

81374 87535 NCCI

81374 87536 NCCI

81374 87537 NCCI

81374 87538 NCCI

81374 87539 NCCI

81374 87540 NCCI

81374 87541 NCCI

81374 87542 NCCI

81374 87550 NCCI

81374 87551 NCCI

81374 87552 NCCI

81374 87555 NCCI

81374 87556 NCCI

81374 87557 NCCI

81374 87560 NCCI

81374 87561 NCCI

81374 87562 NCCI

81374 87580 NCCI

81374 87581 NCCI

81374 87582 NCCI

81374 87590 NCCI

81374 87591 NCCI

81374 87592 NCCI

81374 87623 NCCI

81374 87624 NCCI

Comprehensive ComponentCode Code Source

81374 87625 NCCI

81374 87631 NCCI

81374 87632 NCCI

81374 87633 NCCI

81374 87640 NCCI

81374 87641 NCCI

81374 87650 NCCI

81374 87651 NCCI

81374 87652 NCCI

81374 87653 NCCI

81374 87660 NCCI

81374 87661 NCCI

81374 87797 NCCI

81374 87798 NCCI

81374 87799 NCCI

81374 87800 NCCI

81374 87801 NCCI

81374 88291 NCCI

81374 G0476 NCCI

81375 80500 NCCI

81375 80502 NCCI

81375 81376 NCCI

81375 81377 NCCI

81375 84311 NCCI

81375 86812 NCCI

81375 86816 NCCI

81375 86817 NCCI

81375 87140 NCCI

81375 87143 NCCI

81375 87147 NCCI

81375 87149 NCCI

81375 87150 NCCI

81375 87152 NCCI

81375 87153 NCCI

81375 87158 NCCI

81375 87470 NCCI

81375 87471 NCCI

81375 87472 NCCI

81375 87475 NCCI

81375 87476 NCCI

81375 87477 NCCI

81375 87480 NCCI

81375 87481 NCCI

81375 87482 NCCI

81375 87483 NCCI

81375 87485 NCCI

81375 87486 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 140 of 255

Page 141: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81375 87487 NCCI

81375 87490 NCCI

81375 87491 NCCI

81375 87492 NCCI

81375 87493 NCCI

81375 87495 NCCI

81375 87496 NCCI

81375 87497 NCCI

81375 87498 NCCI

81375 87500 NCCI

81375 87501 NCCI

81375 87502 NCCI

81375 87503 NCCI

81375 87505 NCCI

81375 87506 NCCI

81375 87507 NCCI

81375 87510 NCCI

81375 87511 NCCI

81375 87512 NCCI

81375 87515 NCCI

81375 87516 NCCI

81375 87517 NCCI

81375 87520 NCCI

81375 87521 NCCI

81375 87522 NCCI

81375 87525 NCCI

81375 87526 NCCI

81375 87527 NCCI

81375 87528 NCCI

81375 87529 NCCI

81375 87530 NCCI

81375 87531 NCCI

81375 87532 NCCI

81375 87533 NCCI

81375 87534 NCCI

81375 87535 NCCI

81375 87536 NCCI

81375 87537 NCCI

81375 87538 NCCI

81375 87539 NCCI

81375 87540 NCCI

81375 87541 NCCI

81375 87542 NCCI

81375 87550 NCCI

81375 87551 NCCI

81375 87552 NCCI

81375 87555 NCCI

Comprehensive ComponentCode Code Source

81375 87556 NCCI

81375 87557 NCCI

81375 87560 NCCI

81375 87561 NCCI

81375 87562 NCCI

81375 87580 NCCI

81375 87581 NCCI

81375 87582 NCCI

81375 87590 NCCI

81375 87591 NCCI

81375 87592 NCCI

81375 87623 NCCI

81375 87624 NCCI

81375 87625 NCCI

81375 87631 NCCI

81375 87632 NCCI

81375 87633 NCCI

81375 87640 NCCI

81375 87641 NCCI

81375 87650 NCCI

81375 87651 NCCI

81375 87652 NCCI

81375 87653 NCCI

81375 87660 NCCI

81375 87661 NCCI

81375 87797 NCCI

81375 87798 NCCI

81375 87799 NCCI

81375 87800 NCCI

81375 87801 NCCI

81375 88291 NCCI

81375 G0476 NCCI

81376 80500 NCCI

81376 80502 NCCI

81376 81377 NCCI

81376 84311 NCCI

81376 86816 NCCI

81376 86817 NCCI

81376 87140 NCCI

81376 87143 NCCI

81376 87147 NCCI

81376 87149 NCCI

81376 87150 NCCI

81376 87152 NCCI

81376 87153 NCCI

81376 87158 NCCI

81376 87470 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 141 of 255

Page 142: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81376 87471 NCCI

81376 87472 NCCI

81376 87475 NCCI

81376 87476 NCCI

81376 87477 NCCI

81376 87480 NCCI

81376 87481 NCCI

81376 87482 NCCI

81376 87483 NCCI

81376 87485 NCCI

81376 87486 NCCI

81376 87487 NCCI

81376 87490 NCCI

81376 87491 NCCI

81376 87492 NCCI

81376 87493 NCCI

81376 87495 NCCI

81376 87496 NCCI

81376 87497 NCCI

81376 87498 NCCI

81376 87500 NCCI

81376 87501 NCCI

81376 87502 NCCI

81376 87503 NCCI

81376 87505 NCCI

81376 87506 NCCI

81376 87507 NCCI

81376 87510 NCCI

81376 87511 NCCI

81376 87512 NCCI

81376 87515 NCCI

81376 87516 NCCI

81376 87517 NCCI

81376 87520 NCCI

81376 87521 NCCI

81376 87522 NCCI

81376 87525 NCCI

81376 87526 NCCI

81376 87527 NCCI

81376 87528 NCCI

81376 87529 NCCI

81376 87530 NCCI

81376 87531 NCCI

81376 87532 NCCI

81376 87533 NCCI

81376 87534 NCCI

81376 87535 NCCI

Comprehensive ComponentCode Code Source

81376 87536 NCCI

81376 87537 NCCI

81376 87538 NCCI

81376 87539 NCCI

81376 87540 NCCI

81376 87541 NCCI

81376 87542 NCCI

81376 87550 NCCI

81376 87551 NCCI

81376 87552 NCCI

81376 87555 NCCI

81376 87556 NCCI

81376 87557 NCCI

81376 87560 NCCI

81376 87561 NCCI

81376 87562 NCCI

81376 87580 NCCI

81376 87581 NCCI

81376 87582 NCCI

81376 87590 NCCI

81376 87591 NCCI

81376 87592 NCCI

81376 87623 NCCI

81376 87624 NCCI

81376 87625 NCCI

81376 87631 NCCI

81376 87632 NCCI

81376 87633 NCCI

81376 87640 NCCI

81376 87641 NCCI

81376 87650 NCCI

81376 87651 NCCI

81376 87652 NCCI

81376 87653 NCCI

81376 87660 NCCI

81376 87661 NCCI

81376 87797 NCCI

81376 87798 NCCI

81376 87799 NCCI

81376 87800 NCCI

81376 87801 NCCI

81376 88291 NCCI

81376 G0476 NCCI

81377 80500 NCCI

81377 80502 NCCI

81377 84311 NCCI

81377 86816 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 142 of 255

Page 143: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81377 86817 NCCI

81377 87140 NCCI

81377 87143 NCCI

81377 87147 NCCI

81377 87149 NCCI

81377 87150 NCCI

81377 87152 NCCI

81377 87153 NCCI

81377 87158 NCCI

81377 87470 NCCI

81377 87471 NCCI

81377 87472 NCCI

81377 87475 NCCI

81377 87476 NCCI

81377 87477 NCCI

81377 87480 NCCI

81377 87481 NCCI

81377 87482 NCCI

81377 87483 NCCI

81377 87485 NCCI

81377 87486 NCCI

81377 87487 NCCI

81377 87490 NCCI

81377 87491 NCCI

81377 87492 NCCI

81377 87493 NCCI

81377 87495 NCCI

81377 87496 NCCI

81377 87497 NCCI

81377 87498 NCCI

81377 87500 NCCI

81377 87501 NCCI

81377 87502 NCCI

81377 87503 NCCI

81377 87505 NCCI

81377 87506 NCCI

81377 87507 NCCI

81377 87510 NCCI

81377 87511 NCCI

81377 87512 NCCI

81377 87515 NCCI

81377 87516 NCCI

81377 87517 NCCI

81377 87520 NCCI

81377 87521 NCCI

81377 87522 NCCI

81377 87525 NCCI

Comprehensive ComponentCode Code Source

81377 87526 NCCI

81377 87527 NCCI

81377 87528 NCCI

81377 87529 NCCI

81377 87530 NCCI

81377 87531 NCCI

81377 87532 NCCI

81377 87533 NCCI

81377 87534 NCCI

81377 87535 NCCI

81377 87536 NCCI

81377 87537 NCCI

81377 87538 NCCI

81377 87539 NCCI

81377 87540 NCCI

81377 87541 NCCI

81377 87542 NCCI

81377 87550 NCCI

81377 87551 NCCI

81377 87552 NCCI

81377 87555 NCCI

81377 87556 NCCI

81377 87557 NCCI

81377 87560 NCCI

81377 87561 NCCI

81377 87562 NCCI

81377 87580 NCCI

81377 87581 NCCI

81377 87582 NCCI

81377 87590 NCCI

81377 87591 NCCI

81377 87592 NCCI

81377 87623 NCCI

81377 87624 NCCI

81377 87625 NCCI

81377 87631 NCCI

81377 87632 NCCI

81377 87633 NCCI

81377 87640 NCCI

81377 87641 NCCI

81377 87650 NCCI

81377 87651 NCCI

81377 87652 NCCI

81377 87653 NCCI

81377 87660 NCCI

81377 87661 NCCI

81377 87797 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 143 of 255

Page 144: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81377 87798 NCCI

81377 87799 NCCI

81377 87800 NCCI

81377 87801 NCCI

81377 88291 NCCI

81377 G0476 NCCI

81378 80500 NCCI

81378 80502 NCCI

81378 81370 NCCI

81378 81371 NCCI

81378 81372 NCCI

81378 81373 NCCI

81378 81374 NCCI

81378 81375 NCCI

81378 81376 NCCI

81378 81377 NCCI

81378 81379 NCCI

81378 81380 NCCI

81378 81381 NCCI

81378 81382 NCCI

81378 81383 NCCI

81378 84311 NCCI

81378 86812 NCCI

81378 86813 NCCI

81378 86816 NCCI

81378 86817 NCCI

81378 87140 NCCI

81378 87143 NCCI

81378 87147 NCCI

81378 87149 NCCI

81378 87150 NCCI

81378 87152 NCCI

81378 87153 NCCI

81378 87158 NCCI

81378 87470 NCCI

81378 87471 NCCI

81378 87472 NCCI

81378 87475 NCCI

81378 87476 NCCI

81378 87477 NCCI

81378 87480 NCCI

81378 87481 NCCI

81378 87482 NCCI

81378 87483 NCCI

81378 87485 NCCI

81378 87486 NCCI

81378 87487 NCCI

Comprehensive ComponentCode Code Source

81378 87490 NCCI

81378 87491 NCCI

81378 87492 NCCI

81378 87493 NCCI

81378 87495 NCCI

81378 87496 NCCI

81378 87497 NCCI

81378 87498 NCCI

81378 87500 NCCI

81378 87501 NCCI

81378 87502 NCCI

81378 87503 NCCI

81378 87505 NCCI

81378 87506 NCCI

81378 87507 NCCI

81378 87510 NCCI

81378 87511 NCCI

81378 87512 NCCI

81378 87515 NCCI

81378 87516 NCCI

81378 87517 NCCI

81378 87520 NCCI

81378 87521 NCCI

81378 87522 NCCI

81378 87525 NCCI

81378 87526 NCCI

81378 87527 NCCI

81378 87528 NCCI

81378 87529 NCCI

81378 87530 NCCI

81378 87531 NCCI

81378 87532 NCCI

81378 87533 NCCI

81378 87534 NCCI

81378 87535 NCCI

81378 87536 NCCI

81378 87537 NCCI

81378 87538 NCCI

81378 87539 NCCI

81378 87540 NCCI

81378 87541 NCCI

81378 87542 NCCI

81378 87550 NCCI

81378 87551 NCCI

81378 87552 NCCI

81378 87555 NCCI

81378 87556 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 144 of 255

Page 145: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81378 87557 NCCI

81378 87560 NCCI

81378 87561 NCCI

81378 87562 NCCI

81378 87580 NCCI

81378 87581 NCCI

81378 87582 NCCI

81378 87590 NCCI

81378 87591 NCCI

81378 87592 NCCI

81378 87623 NCCI

81378 87624 NCCI

81378 87625 NCCI

81378 87631 NCCI

81378 87632 NCCI

81378 87633 NCCI

81378 87640 NCCI

81378 87641 NCCI

81378 87650 NCCI

81378 87651 NCCI

81378 87652 NCCI

81378 87653 NCCI

81378 87660 NCCI

81378 87661 NCCI

81378 87797 NCCI

81378 87798 NCCI

81378 87799 NCCI

81378 87800 NCCI

81378 87801 NCCI

81378 88291 NCCI

81378 G0476 NCCI

81379 80500 NCCI

81379 80502 NCCI

81379 81370 NCCI

81379 81371 NCCI

81379 81372 NCCI

81379 81373 NCCI

81379 81374 NCCI

81379 81375 NCCI

81379 81376 NCCI

81379 81377 NCCI

81379 81380 NCCI

81379 81381 NCCI

81379 81382 NCCI

81379 84311 NCCI

81379 86812 NCCI

81379 86813 NCCI

Comprehensive ComponentCode Code Source

81379 87140 NCCI

81379 87143 NCCI

81379 87147 NCCI

81379 87149 NCCI

81379 87150 NCCI

81379 87152 NCCI

81379 87153 NCCI

81379 87158 NCCI

81379 87470 NCCI

81379 87471 NCCI

81379 87472 NCCI

81379 87475 NCCI

81379 87476 NCCI

81379 87477 NCCI

81379 87480 NCCI

81379 87481 NCCI

81379 87482 NCCI

81379 87483 NCCI

81379 87485 NCCI

81379 87486 NCCI

81379 87487 NCCI

81379 87490 NCCI

81379 87491 NCCI

81379 87492 NCCI

81379 87493 NCCI

81379 87495 NCCI

81379 87496 NCCI

81379 87497 NCCI

81379 87498 NCCI

81379 87500 NCCI

81379 87501 NCCI

81379 87502 NCCI

81379 87503 NCCI

81379 87505 NCCI

81379 87506 NCCI

81379 87507 NCCI

81379 87510 NCCI

81379 87511 NCCI

81379 87512 NCCI

81379 87515 NCCI

81379 87516 NCCI

81379 87517 NCCI

81379 87520 NCCI

81379 87521 NCCI

81379 87522 NCCI

81379 87525 NCCI

81379 87526 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 145 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81379 87527 NCCI

81379 87528 NCCI

81379 87529 NCCI

81379 87530 NCCI

81379 87531 NCCI

81379 87532 NCCI

81379 87533 NCCI

81379 87534 NCCI

81379 87535 NCCI

81379 87536 NCCI

81379 87537 NCCI

81379 87538 NCCI

81379 87539 NCCI

81379 87540 NCCI

81379 87541 NCCI

81379 87542 NCCI

81379 87550 NCCI

81379 87551 NCCI

81379 87552 NCCI

81379 87555 NCCI

81379 87556 NCCI

81379 87557 NCCI

81379 87560 NCCI

81379 87561 NCCI

81379 87562 NCCI

81379 87580 NCCI

81379 87581 NCCI

81379 87582 NCCI

81379 87590 NCCI

81379 87591 NCCI

81379 87592 NCCI

81379 87623 NCCI

81379 87624 NCCI

81379 87625 NCCI

81379 87631 NCCI

81379 87632 NCCI

81379 87633 NCCI

81379 87640 NCCI

81379 87641 NCCI

81379 87650 NCCI

81379 87651 NCCI

81379 87652 NCCI

81379 87653 NCCI

81379 87660 NCCI

81379 87661 NCCI

81379 87797 NCCI

81379 87798 NCCI

Comprehensive ComponentCode Code Source

81379 87799 NCCI

81379 87800 NCCI

81379 87801 NCCI

81379 88291 NCCI

81379 G0476 NCCI

81380 80500 NCCI

81380 80502 NCCI

81380 81370 NCCI

81380 81371 NCCI

81380 81372 NCCI

81380 81373 NCCI

81380 81374 NCCI

81380 81375 NCCI

81380 81376 NCCI

81380 81377 NCCI

81380 81381 NCCI

81380 81382 NCCI

81380 84311 NCCI

81380 86812 NCCI

81380 86813 NCCI

81380 86816 NCCI

81380 86817 NCCI

81380 87140 NCCI

81380 87143 NCCI

81380 87147 NCCI

81380 87149 NCCI

81380 87150 NCCI

81380 87152 NCCI

81380 87153 NCCI

81380 87158 NCCI

81380 87470 NCCI

81380 87471 NCCI

81380 87472 NCCI

81380 87475 NCCI

81380 87476 NCCI

81380 87477 NCCI

81380 87480 NCCI

81380 87481 NCCI

81380 87482 NCCI

81380 87483 NCCI

81380 87485 NCCI

81380 87486 NCCI

81380 87487 NCCI

81380 87490 NCCI

81380 87491 NCCI

81380 87492 NCCI

81380 87493 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 146 of 255

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Effective Date of Service: 7/1/2017

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Comprehensive ComponentCode Code Source

81380 87495 NCCI

81380 87496 NCCI

81380 87497 NCCI

81380 87498 NCCI

81380 87500 NCCI

81380 87501 NCCI

81380 87502 NCCI

81380 87503 NCCI

81380 87505 NCCI

81380 87506 NCCI

81380 87507 NCCI

81380 87510 NCCI

81380 87511 NCCI

81380 87512 NCCI

81380 87515 NCCI

81380 87516 NCCI

81380 87517 NCCI

81380 87520 NCCI

81380 87521 NCCI

81380 87522 NCCI

81380 87525 NCCI

81380 87526 NCCI

81380 87527 NCCI

81380 87528 NCCI

81380 87529 NCCI

81380 87530 NCCI

81380 87531 NCCI

81380 87532 NCCI

81380 87533 NCCI

81380 87534 NCCI

81380 87535 NCCI

81380 87536 NCCI

81380 87537 NCCI

81380 87538 NCCI

81380 87539 NCCI

81380 87540 NCCI

81380 87541 NCCI

81380 87542 NCCI

81380 87550 NCCI

81380 87551 NCCI

81380 87552 NCCI

81380 87555 NCCI

81380 87556 NCCI

81380 87557 NCCI

81380 87560 NCCI

81380 87561 NCCI

81380 87562 NCCI

Comprehensive ComponentCode Code Source

81380 87580 NCCI

81380 87581 NCCI

81380 87582 NCCI

81380 87590 NCCI

81380 87591 NCCI

81380 87592 NCCI

81380 87623 NCCI

81380 87624 NCCI

81380 87625 NCCI

81380 87631 NCCI

81380 87632 NCCI

81380 87633 NCCI

81380 87640 NCCI

81380 87641 NCCI

81380 87650 NCCI

81380 87651 NCCI

81380 87652 NCCI

81380 87653 NCCI

81380 87660 NCCI

81380 87661 NCCI

81380 87797 NCCI

81380 87798 NCCI

81380 87799 NCCI

81380 87800 NCCI

81380 87801 NCCI

81380 88291 NCCI

81380 G0476 NCCI

81381 80500 NCCI

81381 80502 NCCI

81381 81370 NCCI

81381 81371 NCCI

81381 81372 NCCI

81381 81373 NCCI

81381 81374 NCCI

81381 81376 NCCI

81381 81377 NCCI

81381 84311 NCCI

81381 86812 NCCI

81381 86813 NCCI

81381 86816 NCCI

81381 86817 NCCI

81381 87140 NCCI

81381 87143 NCCI

81381 87147 NCCI

81381 87149 NCCI

81381 87150 NCCI

81381 87152 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 147 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81381 87153 NCCI

81381 87158 NCCI

81381 87470 NCCI

81381 87471 NCCI

81381 87472 NCCI

81381 87475 NCCI

81381 87476 NCCI

81381 87477 NCCI

81381 87480 NCCI

81381 87481 NCCI

81381 87482 NCCI

81381 87483 NCCI

81381 87485 NCCI

81381 87486 NCCI

81381 87487 NCCI

81381 87490 NCCI

81381 87491 NCCI

81381 87492 NCCI

81381 87493 NCCI

81381 87495 NCCI

81381 87496 NCCI

81381 87497 NCCI

81381 87498 NCCI

81381 87500 NCCI

81381 87501 NCCI

81381 87502 NCCI

81381 87503 NCCI

81381 87505 NCCI

81381 87506 NCCI

81381 87507 NCCI

81381 87510 NCCI

81381 87511 NCCI

81381 87512 NCCI

81381 87515 NCCI

81381 87516 NCCI

81381 87517 NCCI

81381 87520 NCCI

81381 87521 NCCI

81381 87522 NCCI

81381 87525 NCCI

81381 87526 NCCI

81381 87527 NCCI

81381 87528 NCCI

81381 87529 NCCI

81381 87530 NCCI

81381 87531 NCCI

81381 87532 NCCI

Comprehensive ComponentCode Code Source

81381 87533 NCCI

81381 87534 NCCI

81381 87535 NCCI

81381 87536 NCCI

81381 87537 NCCI

81381 87538 NCCI

81381 87539 NCCI

81381 87540 NCCI

81381 87541 NCCI

81381 87542 NCCI

81381 87550 NCCI

81381 87551 NCCI

81381 87552 NCCI

81381 87555 NCCI

81381 87556 NCCI

81381 87557 NCCI

81381 87560 NCCI

81381 87561 NCCI

81381 87562 NCCI

81381 87580 NCCI

81381 87581 NCCI

81381 87582 NCCI

81381 87590 NCCI

81381 87591 NCCI

81381 87592 NCCI

81381 87623 NCCI

81381 87624 NCCI

81381 87625 NCCI

81381 87631 NCCI

81381 87632 NCCI

81381 87633 NCCI

81381 87640 NCCI

81381 87641 NCCI

81381 87650 NCCI

81381 87651 NCCI

81381 87652 NCCI

81381 87653 NCCI

81381 87660 NCCI

81381 87661 NCCI

81381 87797 NCCI

81381 87798 NCCI

81381 87799 NCCI

81381 87800 NCCI

81381 87801 NCCI

81381 88291 NCCI

81381 G0476 NCCI

81382 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 148 of 255

Page 149: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81382 80502 NCCI

81382 81370 NCCI

81382 81375 NCCI

81382 81376 NCCI

81382 81377 NCCI

81382 81383 NCCI

81382 84311 NCCI

81382 86812 NCCI

81382 86813 NCCI

81382 86816 NCCI

81382 86817 NCCI

81382 87140 NCCI

81382 87143 NCCI

81382 87147 NCCI

81382 87149 NCCI

81382 87150 NCCI

81382 87152 NCCI

81382 87153 NCCI

81382 87158 NCCI

81382 87470 NCCI

81382 87471 NCCI

81382 87472 NCCI

81382 87475 NCCI

81382 87476 NCCI

81382 87477 NCCI

81382 87480 NCCI

81382 87481 NCCI

81382 87482 NCCI

81382 87483 NCCI

81382 87485 NCCI

81382 87486 NCCI

81382 87487 NCCI

81382 87490 NCCI

81382 87491 NCCI

81382 87492 NCCI

81382 87493 NCCI

81382 87495 NCCI

81382 87496 NCCI

81382 87497 NCCI

81382 87498 NCCI

81382 87500 NCCI

81382 87501 NCCI

81382 87502 NCCI

81382 87503 NCCI

81382 87505 NCCI

81382 87506 NCCI

81382 87507 NCCI

Comprehensive ComponentCode Code Source

81382 87510 NCCI

81382 87511 NCCI

81382 87512 NCCI

81382 87515 NCCI

81382 87516 NCCI

81382 87517 NCCI

81382 87520 NCCI

81382 87521 NCCI

81382 87522 NCCI

81382 87525 NCCI

81382 87526 NCCI

81382 87527 NCCI

81382 87528 NCCI

81382 87529 NCCI

81382 87530 NCCI

81382 87531 NCCI

81382 87532 NCCI

81382 87533 NCCI

81382 87534 NCCI

81382 87535 NCCI

81382 87536 NCCI

81382 87537 NCCI

81382 87538 NCCI

81382 87539 NCCI

81382 87540 NCCI

81382 87541 NCCI

81382 87542 NCCI

81382 87550 NCCI

81382 87551 NCCI

81382 87552 NCCI

81382 87555 NCCI

81382 87556 NCCI

81382 87557 NCCI

81382 87560 NCCI

81382 87561 NCCI

81382 87562 NCCI

81382 87580 NCCI

81382 87581 NCCI

81382 87582 NCCI

81382 87590 NCCI

81382 87591 NCCI

81382 87592 NCCI

81382 87623 NCCI

81382 87624 NCCI

81382 87625 NCCI

81382 87631 NCCI

81382 87632 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 149 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81382 87633 NCCI

81382 87640 NCCI

81382 87641 NCCI

81382 87650 NCCI

81382 87651 NCCI

81382 87652 NCCI

81382 87653 NCCI

81382 87660 NCCI

81382 87661 NCCI

81382 87797 NCCI

81382 87798 NCCI

81382 87799 NCCI

81382 87800 NCCI

81382 87801 NCCI

81382 88291 NCCI

81382 G0476 NCCI

81383 80500 NCCI

81383 80502 NCCI

81383 81370 NCCI

81383 81371 NCCI

81383 81372 NCCI

81383 81373 NCCI

81383 81374 NCCI

81383 81375 NCCI

81383 81376 NCCI

81383 81377 NCCI

81383 84311 NCCI

81383 86812 NCCI

81383 86813 NCCI

81383 86816 NCCI

81383 86817 NCCI

81383 87140 NCCI

81383 87143 NCCI

81383 87147 NCCI

81383 87149 NCCI

81383 87150 NCCI

81383 87152 NCCI

81383 87153 NCCI

81383 87158 NCCI

81383 87470 NCCI

81383 87471 NCCI

81383 87472 NCCI

81383 87475 NCCI

81383 87476 NCCI

81383 87477 NCCI

81383 87480 NCCI

81383 87481 NCCI

Comprehensive ComponentCode Code Source

81383 87482 NCCI

81383 87483 NCCI

81383 87485 NCCI

81383 87486 NCCI

81383 87487 NCCI

81383 87490 NCCI

81383 87491 NCCI

81383 87492 NCCI

81383 87493 NCCI

81383 87495 NCCI

81383 87496 NCCI

81383 87497 NCCI

81383 87498 NCCI

81383 87500 NCCI

81383 87501 NCCI

81383 87502 NCCI

81383 87503 NCCI

81383 87505 NCCI

81383 87506 NCCI

81383 87507 NCCI

81383 87510 NCCI

81383 87511 NCCI

81383 87512 NCCI

81383 87515 NCCI

81383 87516 NCCI

81383 87517 NCCI

81383 87520 NCCI

81383 87521 NCCI

81383 87522 NCCI

81383 87525 NCCI

81383 87526 NCCI

81383 87527 NCCI

81383 87528 NCCI

81383 87529 NCCI

81383 87530 NCCI

81383 87531 NCCI

81383 87532 NCCI

81383 87533 NCCI

81383 87534 NCCI

81383 87535 NCCI

81383 87536 NCCI

81383 87537 NCCI

81383 87538 NCCI

81383 87539 NCCI

81383 87540 NCCI

81383 87541 NCCI

81383 87542 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 150 of 255

Page 151: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81383 87550 NCCI

81383 87551 NCCI

81383 87552 NCCI

81383 87555 NCCI

81383 87556 NCCI

81383 87557 NCCI

81383 87560 NCCI

81383 87561 NCCI

81383 87562 NCCI

81383 87580 NCCI

81383 87581 NCCI

81383 87582 NCCI

81383 87590 NCCI

81383 87591 NCCI

81383 87592 NCCI

81383 87623 NCCI

81383 87624 NCCI

81383 87625 NCCI

81383 87631 NCCI

81383 87632 NCCI

81383 87633 NCCI

81383 87640 NCCI

81383 87641 NCCI

81383 87650 NCCI

81383 87651 NCCI

81383 87652 NCCI

81383 87653 NCCI

81383 87660 NCCI

81383 87661 NCCI

81383 87797 NCCI

81383 87798 NCCI

81383 87799 NCCI

81383 87800 NCCI

81383 87801 NCCI

81383 88291 NCCI

81383 G0476 NCCI

81400 80500 NCCI

81400 80502 NCCI

81400 84311 NCCI

81400 88271 NCCI

81400 88272 NCCI

81400 88273 NCCI

81400 88274 NCCI

81400 88275 NCCI

81400 88291 NCCI

81400 88364 NCCI

81400 88365 NCCI

Comprehensive ComponentCode Code Source

81400 88366 NCCI

81400 88367 NCCI

81400 88368 NCCI

81400 88369 NCCI

81400 88373 NCCI

81400 88374 NCCI

81400 88377 NCCI

81401 80500 NCCI

81401 80502 NCCI

81401 84311 NCCI

81401 88271 NCCI

81401 88272 NCCI

81401 88273 NCCI

81401 88274 NCCI

81401 88275 NCCI

81401 88291 NCCI

81401 88364 NCCI

81401 88365 NCCI

81401 88366 NCCI

81401 88367 NCCI

81401 88368 NCCI

81401 88369 NCCI

81401 88373 NCCI

81401 88374 NCCI

81401 88377 NCCI

81402 80500 NCCI

81402 80502 NCCI

81402 84311 NCCI

81402 88271 NCCI

81402 88272 NCCI

81402 88273 NCCI

81402 88274 NCCI

81402 88275 NCCI

81402 88291 NCCI

81402 88364 NCCI

81402 88365 NCCI

81402 88366 NCCI

81402 88367 NCCI

81402 88368 NCCI

81402 88369 NCCI

81402 88373 NCCI

81402 88374 NCCI

81402 88377 NCCI

81403 80500 NCCI

81403 80502 NCCI

81403 84311 NCCI

81403 88271 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 151 of 255

Page 152: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81403 88272 NCCI

81403 88273 NCCI

81403 88274 NCCI

81403 88275 NCCI

81403 88291 NCCI

81403 88364 NCCI

81403 88365 NCCI

81403 88366 NCCI

81403 88367 NCCI

81403 88368 NCCI

81403 88369 NCCI

81403 88373 NCCI

81403 88374 NCCI

81403 88377 NCCI

81404 80500 NCCI

81404 80502 NCCI

81404 84311 NCCI

81404 88271 NCCI

81404 88272 NCCI

81404 88273 NCCI

81404 88274 NCCI

81404 88275 NCCI

81404 88291 NCCI

81404 88364 NCCI

81404 88365 NCCI

81404 88366 NCCI

81404 88367 NCCI

81404 88368 NCCI

81404 88369 NCCI

81404 88373 NCCI

81404 88374 NCCI

81404 88377 NCCI

81405 80500 NCCI

81405 80502 NCCI

81405 84311 NCCI

81405 88271 NCCI

81405 88272 NCCI

81405 88273 NCCI

81405 88274 NCCI

81405 88275 NCCI

81405 88291 NCCI

81405 88364 NCCI

81405 88365 NCCI

81405 88366 NCCI

81405 88367 NCCI

81405 88368 NCCI

81405 88369 NCCI

Comprehensive ComponentCode Code Source

81405 88373 NCCI

81405 88374 NCCI

81405 88377 NCCI

81406 80500 NCCI

81406 80502 NCCI

81406 84311 NCCI

81406 88271 NCCI

81406 88272 NCCI

81406 88273 NCCI

81406 88274 NCCI

81406 88275 NCCI

81406 88291 NCCI

81406 88364 NCCI

81406 88365 NCCI

81406 88366 NCCI

81406 88367 NCCI

81406 88368 NCCI

81406 88369 NCCI

81406 88373 NCCI

81406 88374 NCCI

81406 88377 NCCI

81407 80500 NCCI

81407 80502 NCCI

81407 84311 NCCI

81407 88271 NCCI

81407 88272 NCCI

81407 88273 NCCI

81407 88274 NCCI

81407 88275 NCCI

81407 88291 NCCI

81407 88364 NCCI

81407 88365 NCCI

81407 88366 NCCI

81407 88367 NCCI

81407 88368 NCCI

81407 88369 NCCI

81407 88373 NCCI

81407 88374 NCCI

81407 88377 NCCI

81408 80500 NCCI

81408 80502 NCCI

81408 84311 NCCI

81408 88271 NCCI

81408 88272 NCCI

81408 88273 NCCI

81408 88274 NCCI

81408 88275 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 152 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81408 88291 NCCI

81408 88364 NCCI

81408 88365 NCCI

81408 88366 NCCI

81408 88367 NCCI

81408 88368 NCCI

81408 88369 NCCI

81408 88373 NCCI

81408 88374 NCCI

81408 88377 NCCI

81410 80500 NCCI

81410 80502 NCCI

81410 81161 NCCI

81410 81162 NCCI

81410 81170 NCCI

81410 81200 NCCI

81410 81201 NCCI

81410 81202 NCCI

81410 81203 NCCI

81410 81205 NCCI

81410 81206 NCCI

81410 81207 NCCI

81410 81208 NCCI

81410 81209 NCCI

81410 81210 NCCI

81410 81211 NCCI

81410 81212 NCCI

81410 81213 NCCI

81410 81214 NCCI

81410 81215 NCCI

81410 81216 NCCI

81410 81217 NCCI

81410 81218 NCCI

81410 81219 NCCI

81410 81220 NCCI

81410 81221 NCCI

81410 81222 NCCI

81410 81223 NCCI

81410 81224 NCCI

81410 81225 NCCI

81410 81226 NCCI

81410 81227 NCCI

81410 81235 NCCI

81410 81240 NCCI

81410 81241 NCCI

81410 81242 NCCI

81410 81243 NCCI

Comprehensive ComponentCode Code Source

81410 81244 NCCI

81410 81245 NCCI

81410 81246 NCCI

81410 81250 NCCI

81410 81251 NCCI

81410 81252 NCCI

81410 81253 NCCI

81410 81254 NCCI

81410 81255 NCCI

81410 81256 NCCI

81410 81257 NCCI

81410 81260 NCCI

81410 81261 NCCI

81410 81262 NCCI

81410 81263 NCCI

81410 81264 NCCI

81410 81265 NCCI

81410 81266 NCCI

81410 81267 NCCI

81410 81268 NCCI

81410 81270 NCCI

81410 81272 NCCI

81410 81273 NCCI

81410 81275 NCCI

81410 81276 NCCI

81410 81287 NCCI

81410 81288 NCCI

81410 81290 NCCI

81410 81291 NCCI

81410 81292 NCCI

81410 81293 NCCI

81410 81294 NCCI

81410 81295 NCCI

81410 81296 NCCI

81410 81297 NCCI

81410 81298 NCCI

81410 81299 NCCI

81410 81300 NCCI

81410 81301 NCCI

81410 81302 NCCI

81410 81303 NCCI

81410 81304 NCCI

81410 81310 NCCI

81410 81311 NCCI

81410 81313 NCCI

81410 81314 NCCI

81410 81315 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 153 of 255

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Comprehensive ComponentCode Code Source

81410 81316 NCCI

81410 81317 NCCI

81410 81318 NCCI

81410 81319 NCCI

81410 81321 NCCI

81410 81322 NCCI

81410 81323 NCCI

81410 81324 NCCI

81410 81325 NCCI

81410 81326 NCCI

81410 81327 NCCI

81410 81330 NCCI

81410 81331 NCCI

81410 81332 NCCI

81410 81340 NCCI

81410 81341 NCCI

81410 81342 NCCI

81410 81350 NCCI

81410 81355 NCCI

81410 81400 NCCI

81410 81401 NCCI

81410 81402 NCCI

81410 81403 NCCI

81410 81404 NCCI

81410 81405 NCCI

81410 81406 NCCI

81410 81407 NCCI

81410 81408 NCCI

81410 81493 NCCI

81410 81504 NCCI

81410 81507 NCCI

81410 81519 NCCI

81410 81525 NCCI

81410 81528 NCCI

81410 81540 NCCI

81410 81545 NCCI

81410 81595 NCCI

81410 84311 NCCI

81410 88271 NCCI

81410 88272 NCCI

81410 88273 NCCI

81410 88274 NCCI

81410 88275 NCCI

81410 88291 NCCI

81410 88364 NCCI

81410 88365 NCCI

81410 88366 NCCI

Comprehensive ComponentCode Code Source

81410 88367 NCCI

81410 88368 NCCI

81410 88369 NCCI

81410 88373 NCCI

81410 88374 NCCI

81410 88377 NCCI

81410 G0452 NCCI

81411 80500 NCCI

81411 80502 NCCI

81411 81161 NCCI

81411 81162 NCCI

81411 81170 NCCI

81411 81200 NCCI

81411 81201 NCCI

81411 81202 NCCI

81411 81203 NCCI

81411 81205 NCCI

81411 81206 NCCI

81411 81207 NCCI

81411 81208 NCCI

81411 81209 NCCI

81411 81210 NCCI

81411 81211 NCCI

81411 81212 NCCI

81411 81213 NCCI

81411 81214 NCCI

81411 81215 NCCI

81411 81216 NCCI

81411 81217 NCCI

81411 81218 NCCI

81411 81219 NCCI

81411 81220 NCCI

81411 81221 NCCI

81411 81222 NCCI

81411 81223 NCCI

81411 81224 NCCI

81411 81225 NCCI

81411 81226 NCCI

81411 81227 NCCI

81411 81235 NCCI

81411 81240 NCCI

81411 81241 NCCI

81411 81242 NCCI

81411 81243 NCCI

81411 81244 NCCI

81411 81245 NCCI

81411 81246 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 154 of 255

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Comprehensive ComponentCode Code Source

81411 81250 NCCI

81411 81251 NCCI

81411 81252 NCCI

81411 81253 NCCI

81411 81254 NCCI

81411 81255 NCCI

81411 81256 NCCI

81411 81257 NCCI

81411 81260 NCCI

81411 81261 NCCI

81411 81262 NCCI

81411 81263 NCCI

81411 81264 NCCI

81411 81265 NCCI

81411 81266 NCCI

81411 81267 NCCI

81411 81268 NCCI

81411 81270 NCCI

81411 81272 NCCI

81411 81273 NCCI

81411 81275 NCCI

81411 81276 NCCI

81411 81287 NCCI

81411 81288 NCCI

81411 81290 NCCI

81411 81291 NCCI

81411 81292 NCCI

81411 81293 NCCI

81411 81294 NCCI

81411 81295 NCCI

81411 81296 NCCI

81411 81297 NCCI

81411 81298 NCCI

81411 81299 NCCI

81411 81300 NCCI

81411 81301 NCCI

81411 81302 NCCI

81411 81303 NCCI

81411 81304 NCCI

81411 81310 NCCI

81411 81311 NCCI

81411 81313 NCCI

81411 81314 NCCI

81411 81315 NCCI

81411 81316 NCCI

81411 81317 NCCI

81411 81318 NCCI

Comprehensive ComponentCode Code Source

81411 81319 NCCI

81411 81321 NCCI

81411 81322 NCCI

81411 81323 NCCI

81411 81324 NCCI

81411 81325 NCCI

81411 81326 NCCI

81411 81327 NCCI

81411 81330 NCCI

81411 81331 NCCI

81411 81332 NCCI

81411 81340 NCCI

81411 81341 NCCI

81411 81342 NCCI

81411 81350 NCCI

81411 81355 NCCI

81411 81400 NCCI

81411 81401 NCCI

81411 81402 NCCI

81411 81403 NCCI

81411 81404 NCCI

81411 81405 NCCI

81411 81406 NCCI

81411 81407 NCCI

81411 81408 NCCI

81411 81493 NCCI

81411 81504 NCCI

81411 81507 NCCI

81411 81519 NCCI

81411 81525 NCCI

81411 81528 NCCI

81411 81540 NCCI

81411 81545 NCCI

81411 81595 NCCI

81411 84311 NCCI

81411 88271 NCCI

81411 88272 NCCI

81411 88273 NCCI

81411 88274 NCCI

81411 88275 NCCI

81411 88291 NCCI

81411 88364 NCCI

81411 88365 NCCI

81411 88366 NCCI

81411 88367 NCCI

81411 88368 NCCI

81411 88369 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 155 of 255

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Comprehensive ComponentCode Code Source

81411 88373 NCCI

81411 88374 NCCI

81411 88377 NCCI

81411 G0452 NCCI

81412 80500 NCCI

81412 80502 NCCI

81412 81161 NCCI

81412 81162 NCCI

81412 81170 NCCI

81412 81200 NCCI

81412 81201 NCCI

81412 81202 NCCI

81412 81203 NCCI

81412 81205 NCCI

81412 81206 NCCI

81412 81207 NCCI

81412 81208 NCCI

81412 81209 NCCI

81412 81210 NCCI

81412 81211 NCCI

81412 81212 NCCI

81412 81213 NCCI

81412 81214 NCCI

81412 81215 NCCI

81412 81216 NCCI

81412 81217 NCCI

81412 81218 NCCI

81412 81219 NCCI

81412 81220 NCCI

81412 81221 NCCI

81412 81222 NCCI

81412 81223 NCCI

81412 81224 NCCI

81412 81225 NCCI

81412 81226 NCCI

81412 81227 NCCI

81412 81235 NCCI

81412 81240 NCCI

81412 81241 NCCI

81412 81242 NCCI

81412 81243 NCCI

81412 81244 NCCI

81412 81245 NCCI

81412 81246 NCCI

81412 81250 NCCI

81412 81251 NCCI

81412 81252 NCCI

Comprehensive ComponentCode Code Source

81412 81253 NCCI

81412 81254 NCCI

81412 81255 NCCI

81412 81256 NCCI

81412 81257 NCCI

81412 81260 NCCI

81412 81261 NCCI

81412 81262 NCCI

81412 81263 NCCI

81412 81264 NCCI

81412 81265 NCCI

81412 81266 NCCI

81412 81267 NCCI

81412 81268 NCCI

81412 81270 NCCI

81412 81272 NCCI

81412 81273 NCCI

81412 81275 NCCI

81412 81276 NCCI

81412 81287 NCCI

81412 81288 NCCI

81412 81290 NCCI

81412 81291 NCCI

81412 81292 NCCI

81412 81293 NCCI

81412 81294 NCCI

81412 81295 NCCI

81412 81296 NCCI

81412 81297 NCCI

81412 81298 NCCI

81412 81299 NCCI

81412 81300 NCCI

81412 81301 NCCI

81412 81302 NCCI

81412 81303 NCCI

81412 81304 NCCI

81412 81310 NCCI

81412 81311 NCCI

81412 81313 NCCI

81412 81314 NCCI

81412 81315 NCCI

81412 81316 NCCI

81412 81317 NCCI

81412 81318 NCCI

81412 81319 NCCI

81412 81321 NCCI

81412 81322 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 156 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81412 81323 NCCI

81412 81324 NCCI

81412 81325 NCCI

81412 81326 NCCI

81412 81327 NCCI

81412 81330 NCCI

81412 81331 NCCI

81412 81332 NCCI

81412 81340 NCCI

81412 81341 NCCI

81412 81342 NCCI

81412 81350 NCCI

81412 81355 NCCI

81412 81400 NCCI

81412 81401 NCCI

81412 81402 NCCI

81412 81403 NCCI

81412 81404 NCCI

81412 81405 NCCI

81412 81406 NCCI

81412 81407 NCCI

81412 81408 NCCI

81412 81493 NCCI

81412 81504 NCCI

81412 81507 NCCI

81412 81519 NCCI

81412 81525 NCCI

81412 81528 NCCI

81412 81540 NCCI

81412 81545 NCCI

81412 81595 NCCI

81412 84311 NCCI

81412 88271 NCCI

81412 88272 NCCI

81412 88273 NCCI

81412 88274 NCCI

81412 88275 NCCI

81412 88291 NCCI

81412 88364 NCCI

81412 88365 NCCI

81412 88366 NCCI

81412 88367 NCCI

81412 88368 NCCI

81412 88369 NCCI

81412 88373 NCCI

81412 88374 NCCI

81412 88377 NCCI

Comprehensive ComponentCode Code Source

81412 G0452 NCCI

81413 80500 NCCI

81413 80502 NCCI

81413 81161 NCCI

81413 81162 NCCI

81413 81170 NCCI

81413 81200 NCCI

81413 81201 NCCI

81413 81202 NCCI

81413 81203 NCCI

81413 81205 NCCI

81413 81206 NCCI

81413 81207 NCCI

81413 81208 NCCI

81413 81209 NCCI

81413 81210 NCCI

81413 81211 NCCI

81413 81212 NCCI

81413 81213 NCCI

81413 81214 NCCI

81413 81215 NCCI

81413 81216 NCCI

81413 81217 NCCI

81413 81218 NCCI

81413 81219 NCCI

81413 81220 NCCI

81413 81221 NCCI

81413 81222 NCCI

81413 81223 NCCI

81413 81224 NCCI

81413 81225 NCCI

81413 81226 NCCI

81413 81227 NCCI

81413 81228 NCCI

81413 81229 NCCI

81413 81235 NCCI

81413 81240 NCCI

81413 81241 NCCI

81413 81242 NCCI

81413 81243 NCCI

81413 81244 NCCI

81413 81245 NCCI

81413 81246 NCCI

81413 81250 NCCI

81413 81251 NCCI

81413 81252 NCCI

81413 81253 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 157 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81413 81254 NCCI

81413 81255 NCCI

81413 81256 NCCI

81413 81257 NCCI

81413 81260 NCCI

81413 81261 NCCI

81413 81262 NCCI

81413 81263 NCCI

81413 81264 NCCI

81413 81265 NCCI

81413 81266 NCCI

81413 81267 NCCI

81413 81268 NCCI

81413 81270 NCCI

81413 81272 NCCI

81413 81273 NCCI

81413 81275 NCCI

81413 81276 NCCI

81413 81287 NCCI

81413 81288 NCCI

81413 81290 NCCI

81413 81291 NCCI

81413 81292 NCCI

81413 81293 NCCI

81413 81294 NCCI

81413 81295 NCCI

81413 81296 NCCI

81413 81297 NCCI

81413 81298 NCCI

81413 81299 NCCI

81413 81300 NCCI

81413 81301 NCCI

81413 81302 NCCI

81413 81303 NCCI

81413 81304 NCCI

81413 81310 NCCI

81413 81311 NCCI

81413 81313 NCCI

81413 81314 NCCI

81413 81315 NCCI

81413 81316 NCCI

81413 81317 NCCI

81413 81318 NCCI

81413 81319 NCCI

81413 81321 NCCI

81413 81322 NCCI

81413 81323 NCCI

Comprehensive ComponentCode Code Source

81413 81324 NCCI

81413 81325 NCCI

81413 81326 NCCI

81413 81327 NCCI

81413 81330 NCCI

81413 81331 NCCI

81413 81332 NCCI

81413 81340 NCCI

81413 81341 NCCI

81413 81342 NCCI

81413 81350 NCCI

81413 81355 NCCI

81413 81400 NCCI

81413 81401 NCCI

81413 81402 NCCI

81413 81403 NCCI

81413 81404 NCCI

81413 81405 NCCI

81413 81406 NCCI

81413 81407 NCCI

81413 81408 NCCI

81413 81493 NCCI

81413 81504 NCCI

81413 81507 NCCI

81413 81519 NCCI

81413 81525 NCCI

81413 81528 NCCI

81413 81540 NCCI

81413 81545 NCCI

81413 81595 NCCI

81413 84311 NCCI

81413 88271 NCCI

81413 88272 NCCI

81413 88273 NCCI

81413 88274 NCCI

81413 88275 NCCI

81413 88291 NCCI

81413 88364 NCCI

81413 88365 NCCI

81413 88366 NCCI

81413 88367 NCCI

81413 88368 NCCI

81413 88369 NCCI

81413 88373 NCCI

81413 88374 NCCI

81413 88377 NCCI

81413 96523 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 158 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81413 G0452 NCCI

81414 80500 NCCI

81414 80502 NCCI

81414 81161 NCCI

81414 81162 NCCI

81414 81170 NCCI

81414 81200 NCCI

81414 81201 NCCI

81414 81202 NCCI

81414 81203 NCCI

81414 81205 NCCI

81414 81206 NCCI

81414 81207 NCCI

81414 81208 NCCI

81414 81209 NCCI

81414 81210 NCCI

81414 81211 NCCI

81414 81212 NCCI

81414 81213 NCCI

81414 81214 NCCI

81414 81215 NCCI

81414 81216 NCCI

81414 81217 NCCI

81414 81218 NCCI

81414 81219 NCCI

81414 81220 NCCI

81414 81221 NCCI

81414 81222 NCCI

81414 81223 NCCI

81414 81224 NCCI

81414 81225 NCCI

81414 81226 NCCI

81414 81227 NCCI

81414 81228 NCCI

81414 81229 NCCI

81414 81235 NCCI

81414 81240 NCCI

81414 81241 NCCI

81414 81242 NCCI

81414 81243 NCCI

81414 81244 NCCI

81414 81245 NCCI

81414 81246 NCCI

81414 81250 NCCI

81414 81251 NCCI

81414 81252 NCCI

81414 81253 NCCI

Comprehensive ComponentCode Code Source

81414 81254 NCCI

81414 81255 NCCI

81414 81256 NCCI

81414 81257 NCCI

81414 81260 NCCI

81414 81261 NCCI

81414 81262 NCCI

81414 81263 NCCI

81414 81264 NCCI

81414 81265 NCCI

81414 81266 NCCI

81414 81267 NCCI

81414 81268 NCCI

81414 81270 NCCI

81414 81272 NCCI

81414 81273 NCCI

81414 81275 NCCI

81414 81276 NCCI

81414 81287 NCCI

81414 81288 NCCI

81414 81290 NCCI

81414 81291 NCCI

81414 81292 NCCI

81414 81293 NCCI

81414 81294 NCCI

81414 81295 NCCI

81414 81296 NCCI

81414 81297 NCCI

81414 81298 NCCI

81414 81299 NCCI

81414 81300 NCCI

81414 81301 NCCI

81414 81302 NCCI

81414 81303 NCCI

81414 81304 NCCI

81414 81310 NCCI

81414 81311 NCCI

81414 81313 NCCI

81414 81314 NCCI

81414 81315 NCCI

81414 81316 NCCI

81414 81317 NCCI

81414 81318 NCCI

81414 81319 NCCI

81414 81321 NCCI

81414 81322 NCCI

81414 81323 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 159 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81414 81324 NCCI

81414 81325 NCCI

81414 81326 NCCI

81414 81327 NCCI

81414 81330 NCCI

81414 81331 NCCI

81414 81332 NCCI

81414 81340 NCCI

81414 81341 NCCI

81414 81342 NCCI

81414 81350 NCCI

81414 81355 NCCI

81414 81400 NCCI

81414 81401 NCCI

81414 81402 NCCI

81414 81403 NCCI

81414 81404 NCCI

81414 81405 NCCI

81414 81406 NCCI

81414 81407 NCCI

81414 81408 NCCI

81414 81493 NCCI

81414 81504 NCCI

81414 81507 NCCI

81414 81519 NCCI

81414 81525 NCCI

81414 81528 NCCI

81414 81540 NCCI

81414 81545 NCCI

81414 81595 NCCI

81414 84311 NCCI

81414 88271 NCCI

81414 88272 NCCI

81414 88273 NCCI

81414 88274 NCCI

81414 88275 NCCI

81414 88291 NCCI

81414 88364 NCCI

81414 88365 NCCI

81414 88366 NCCI

81414 88367 NCCI

81414 88368 NCCI

81414 88369 NCCI

81414 88373 NCCI

81414 88374 NCCI

81414 88377 NCCI

81414 96523 NCCI

Comprehensive ComponentCode Code Source

81414 G0452 NCCI

81415 80500 NCCI

81415 80502 NCCI

81415 81161 NCCI

81415 81162 NCCI

81415 81170 NCCI

81415 81200 NCCI

81415 81201 NCCI

81415 81202 NCCI

81415 81203 NCCI

81415 81205 NCCI

81415 81206 NCCI

81415 81207 NCCI

81415 81208 NCCI

81415 81209 NCCI

81415 81210 NCCI

81415 81211 NCCI

81415 81212 NCCI

81415 81213 NCCI

81415 81214 NCCI

81415 81215 NCCI

81415 81216 NCCI

81415 81217 NCCI

81415 81218 NCCI

81415 81219 NCCI

81415 81220 NCCI

81415 81221 NCCI

81415 81222 NCCI

81415 81223 NCCI

81415 81224 NCCI

81415 81225 NCCI

81415 81226 NCCI

81415 81227 NCCI

81415 81235 NCCI

81415 81240 NCCI

81415 81241 NCCI

81415 81242 NCCI

81415 81243 NCCI

81415 81244 NCCI

81415 81245 NCCI

81415 81246 NCCI

81415 81250 NCCI

81415 81251 NCCI

81415 81252 NCCI

81415 81253 NCCI

81415 81254 NCCI

81415 81255 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 160 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81415 81256 NCCI

81415 81257 NCCI

81415 81260 NCCI

81415 81261 NCCI

81415 81262 NCCI

81415 81263 NCCI

81415 81264 NCCI

81415 81265 NCCI

81415 81266 NCCI

81415 81267 NCCI

81415 81268 NCCI

81415 81270 NCCI

81415 81272 NCCI

81415 81273 NCCI

81415 81275 NCCI

81415 81276 NCCI

81415 81287 NCCI

81415 81288 NCCI

81415 81290 NCCI

81415 81291 NCCI

81415 81292 NCCI

81415 81293 NCCI

81415 81294 NCCI

81415 81295 NCCI

81415 81296 NCCI

81415 81297 NCCI

81415 81298 NCCI

81415 81299 NCCI

81415 81300 NCCI

81415 81301 NCCI

81415 81302 NCCI

81415 81303 NCCI

81415 81304 NCCI

81415 81310 NCCI

81415 81311 NCCI

81415 81313 NCCI

81415 81314 NCCI

81415 81315 NCCI

81415 81316 NCCI

81415 81317 NCCI

81415 81318 NCCI

81415 81319 NCCI

81415 81321 NCCI

81415 81322 NCCI

81415 81323 NCCI

81415 81324 NCCI

81415 81325 NCCI

Comprehensive ComponentCode Code Source

81415 81326 NCCI

81415 81327 NCCI

81415 81330 NCCI

81415 81331 NCCI

81415 81332 NCCI

81415 81340 NCCI

81415 81341 NCCI

81415 81342 NCCI

81415 81350 NCCI

81415 81355 NCCI

81415 81400 NCCI

81415 81401 NCCI

81415 81402 NCCI

81415 81403 NCCI

81415 81404 NCCI

81415 81405 NCCI

81415 81406 NCCI

81415 81407 NCCI

81415 81408 NCCI

81415 81493 NCCI

81415 81504 NCCI

81415 81507 NCCI

81415 81519 NCCI

81415 81525 NCCI

81415 81528 NCCI

81415 81540 NCCI

81415 81545 NCCI

81415 81595 NCCI

81415 84311 NCCI

81415 88271 NCCI

81415 88272 NCCI

81415 88273 NCCI

81415 88274 NCCI

81415 88275 NCCI

81415 88291 NCCI

81415 88364 NCCI

81415 88365 NCCI

81415 88366 NCCI

81415 88367 NCCI

81415 88368 NCCI

81415 88369 NCCI

81415 88373 NCCI

81415 88374 NCCI

81415 88377 NCCI

81415 G0452 NCCI

81416 80500 NCCI

81416 80502 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 161 of 255

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Comprehensive ComponentCode Code Source

81416 81161 NCCI

81416 81162 NCCI

81416 81170 NCCI

81416 81200 NCCI

81416 81201 NCCI

81416 81202 NCCI

81416 81203 NCCI

81416 81205 NCCI

81416 81206 NCCI

81416 81207 NCCI

81416 81208 NCCI

81416 81209 NCCI

81416 81210 NCCI

81416 81211 NCCI

81416 81212 NCCI

81416 81213 NCCI

81416 81214 NCCI

81416 81215 NCCI

81416 81216 NCCI

81416 81217 NCCI

81416 81218 NCCI

81416 81219 NCCI

81416 81220 NCCI

81416 81221 NCCI

81416 81222 NCCI

81416 81223 NCCI

81416 81224 NCCI

81416 81225 NCCI

81416 81226 NCCI

81416 81227 NCCI

81416 81235 NCCI

81416 81240 NCCI

81416 81241 NCCI

81416 81242 NCCI

81416 81243 NCCI

81416 81244 NCCI

81416 81245 NCCI

81416 81246 NCCI

81416 81250 NCCI

81416 81251 NCCI

81416 81252 NCCI

81416 81253 NCCI

81416 81254 NCCI

81416 81255 NCCI

81416 81256 NCCI

81416 81257 NCCI

81416 81260 NCCI

Comprehensive ComponentCode Code Source

81416 81261 NCCI

81416 81262 NCCI

81416 81263 NCCI

81416 81264 NCCI

81416 81265 NCCI

81416 81266 NCCI

81416 81267 NCCI

81416 81268 NCCI

81416 81270 NCCI

81416 81272 NCCI

81416 81273 NCCI

81416 81275 NCCI

81416 81276 NCCI

81416 81287 NCCI

81416 81288 NCCI

81416 81290 NCCI

81416 81291 NCCI

81416 81292 NCCI

81416 81293 NCCI

81416 81294 NCCI

81416 81295 NCCI

81416 81296 NCCI

81416 81297 NCCI

81416 81298 NCCI

81416 81299 NCCI

81416 81300 NCCI

81416 81301 NCCI

81416 81302 NCCI

81416 81303 NCCI

81416 81304 NCCI

81416 81310 NCCI

81416 81311 NCCI

81416 81313 NCCI

81416 81314 NCCI

81416 81315 NCCI

81416 81316 NCCI

81416 81317 NCCI

81416 81318 NCCI

81416 81319 NCCI

81416 81321 NCCI

81416 81322 NCCI

81416 81323 NCCI

81416 81324 NCCI

81416 81325 NCCI

81416 81326 NCCI

81416 81327 NCCI

81416 81330 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 162 of 255

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Comprehensive ComponentCode Code Source

81416 81331 NCCI

81416 81332 NCCI

81416 81340 NCCI

81416 81341 NCCI

81416 81342 NCCI

81416 81350 NCCI

81416 81355 NCCI

81416 81400 NCCI

81416 81401 NCCI

81416 81402 NCCI

81416 81403 NCCI

81416 81404 NCCI

81416 81405 NCCI

81416 81406 NCCI

81416 81407 NCCI

81416 81408 NCCI

81416 81493 NCCI

81416 81504 NCCI

81416 81507 NCCI

81416 81519 NCCI

81416 81525 NCCI

81416 81528 NCCI

81416 81540 NCCI

81416 81545 NCCI

81416 81595 NCCI

81416 84311 NCCI

81416 88271 NCCI

81416 88272 NCCI

81416 88273 NCCI

81416 88274 NCCI

81416 88275 NCCI

81416 88291 NCCI

81416 88364 NCCI

81416 88365 NCCI

81416 88366 NCCI

81416 88367 NCCI

81416 88368 NCCI

81416 88369 NCCI

81416 88373 NCCI

81416 88374 NCCI

81416 88377 NCCI

81416 G0452 NCCI

81417 80500 NCCI

81417 80502 NCCI

81417 81161 NCCI

81417 81162 NCCI

81417 81170 NCCI

Comprehensive ComponentCode Code Source

81417 81200 NCCI

81417 81201 NCCI

81417 81202 NCCI

81417 81203 NCCI

81417 81205 NCCI

81417 81206 NCCI

81417 81207 NCCI

81417 81208 NCCI

81417 81209 NCCI

81417 81210 NCCI

81417 81211 NCCI

81417 81212 NCCI

81417 81213 NCCI

81417 81214 NCCI

81417 81215 NCCI

81417 81216 NCCI

81417 81217 NCCI

81417 81218 NCCI

81417 81219 NCCI

81417 81220 NCCI

81417 81221 NCCI

81417 81222 NCCI

81417 81223 NCCI

81417 81224 NCCI

81417 81225 NCCI

81417 81226 NCCI

81417 81227 NCCI

81417 81235 NCCI

81417 81240 NCCI

81417 81241 NCCI

81417 81242 NCCI

81417 81243 NCCI

81417 81244 NCCI

81417 81245 NCCI

81417 81246 NCCI

81417 81250 NCCI

81417 81251 NCCI

81417 81252 NCCI

81417 81253 NCCI

81417 81254 NCCI

81417 81255 NCCI

81417 81256 NCCI

81417 81257 NCCI

81417 81260 NCCI

81417 81261 NCCI

81417 81262 NCCI

81417 81263 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 163 of 255

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Comprehensive ComponentCode Code Source

81417 81264 NCCI

81417 81265 NCCI

81417 81266 NCCI

81417 81267 NCCI

81417 81268 NCCI

81417 81270 NCCI

81417 81272 NCCI

81417 81273 NCCI

81417 81275 NCCI

81417 81276 NCCI

81417 81287 NCCI

81417 81288 NCCI

81417 81290 NCCI

81417 81291 NCCI

81417 81292 NCCI

81417 81293 NCCI

81417 81294 NCCI

81417 81295 NCCI

81417 81296 NCCI

81417 81297 NCCI

81417 81298 NCCI

81417 81299 NCCI

81417 81300 NCCI

81417 81301 NCCI

81417 81302 NCCI

81417 81303 NCCI

81417 81304 NCCI

81417 81310 NCCI

81417 81311 NCCI

81417 81313 NCCI

81417 81314 NCCI

81417 81315 NCCI

81417 81316 NCCI

81417 81317 NCCI

81417 81318 NCCI

81417 81319 NCCI

81417 81321 NCCI

81417 81322 NCCI

81417 81323 NCCI

81417 81324 NCCI

81417 81325 NCCI

81417 81326 NCCI

81417 81327 NCCI

81417 81330 NCCI

81417 81331 NCCI

81417 81332 NCCI

81417 81340 NCCI

Comprehensive ComponentCode Code Source

81417 81341 NCCI

81417 81342 NCCI

81417 81350 NCCI

81417 81355 NCCI

81417 81400 NCCI

81417 81401 NCCI

81417 81402 NCCI

81417 81403 NCCI

81417 81404 NCCI

81417 81405 NCCI

81417 81406 NCCI

81417 81407 NCCI

81417 81408 NCCI

81417 81493 NCCI

81417 81504 NCCI

81417 81507 NCCI

81417 81519 NCCI

81417 81525 NCCI

81417 81528 NCCI

81417 81540 NCCI

81417 81545 NCCI

81417 81595 NCCI

81417 84311 NCCI

81417 88271 NCCI

81417 88272 NCCI

81417 88273 NCCI

81417 88274 NCCI

81417 88275 NCCI

81417 88291 NCCI

81417 88364 NCCI

81417 88365 NCCI

81417 88366 NCCI

81417 88367 NCCI

81417 88368 NCCI

81417 88369 NCCI

81417 88373 NCCI

81417 88374 NCCI

81417 88377 NCCI

81417 G0452 NCCI

81420 80500 NCCI

81420 80502 NCCI

81420 81161 NCCI

81420 81162 NCCI

81420 81170 NCCI

81420 81200 NCCI

81420 81201 NCCI

81420 81202 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 164 of 255

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Comprehensive ComponentCode Code Source

81420 81203 NCCI

81420 81205 NCCI

81420 81206 NCCI

81420 81207 NCCI

81420 81208 NCCI

81420 81209 NCCI

81420 81210 NCCI

81420 81211 NCCI

81420 81212 NCCI

81420 81213 NCCI

81420 81214 NCCI

81420 81215 NCCI

81420 81216 NCCI

81420 81217 NCCI

81420 81218 NCCI

81420 81219 NCCI

81420 81220 NCCI

81420 81221 NCCI

81420 81222 NCCI

81420 81223 NCCI

81420 81224 NCCI

81420 81225 NCCI

81420 81226 NCCI

81420 81227 NCCI

81420 81235 NCCI

81420 81240 NCCI

81420 81241 NCCI

81420 81242 NCCI

81420 81243 NCCI

81420 81244 NCCI

81420 81245 NCCI

81420 81246 NCCI

81420 81250 NCCI

81420 81251 NCCI

81420 81252 NCCI

81420 81253 NCCI

81420 81254 NCCI

81420 81255 NCCI

81420 81256 NCCI

81420 81257 NCCI

81420 81260 NCCI

81420 81261 NCCI

81420 81262 NCCI

81420 81263 NCCI

81420 81264 NCCI

81420 81265 NCCI

81420 81266 NCCI

Comprehensive ComponentCode Code Source

81420 81267 NCCI

81420 81268 NCCI

81420 81270 NCCI

81420 81272 NCCI

81420 81273 NCCI

81420 81275 NCCI

81420 81276 NCCI

81420 81287 NCCI

81420 81288 NCCI

81420 81290 NCCI

81420 81291 NCCI

81420 81292 NCCI

81420 81293 NCCI

81420 81294 NCCI

81420 81295 NCCI

81420 81296 NCCI

81420 81297 NCCI

81420 81298 NCCI

81420 81299 NCCI

81420 81300 NCCI

81420 81301 NCCI

81420 81302 NCCI

81420 81303 NCCI

81420 81304 NCCI

81420 81310 NCCI

81420 81311 NCCI

81420 81313 NCCI

81420 81314 NCCI

81420 81315 NCCI

81420 81316 NCCI

81420 81317 NCCI

81420 81318 NCCI

81420 81319 NCCI

81420 81321 NCCI

81420 81322 NCCI

81420 81323 NCCI

81420 81324 NCCI

81420 81325 NCCI

81420 81326 NCCI

81420 81327 NCCI

81420 81330 NCCI

81420 81331 NCCI

81420 81332 NCCI

81420 81340 NCCI

81420 81341 NCCI

81420 81342 NCCI

81420 81350 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 165 of 255

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Comprehensive ComponentCode Code Source

81420 81355 NCCI

81420 81400 NCCI

81420 81401 NCCI

81420 81402 NCCI

81420 81403 NCCI

81420 81404 NCCI

81420 81405 NCCI

81420 81406 NCCI

81420 81407 NCCI

81420 81408 NCCI

81420 81493 NCCI

81420 81504 NCCI

81420 81507 NCCI

81420 81519 NCCI

81420 81525 NCCI

81420 81528 NCCI

81420 81540 NCCI

81420 81545 NCCI

81420 81595 NCCI

81420 84311 NCCI

81420 88271 NCCI

81420 88272 NCCI

81420 88273 NCCI

81420 88274 NCCI

81420 88275 NCCI

81420 88291 NCCI

81420 88364 NCCI

81420 88365 NCCI

81420 88366 NCCI

81420 88367 NCCI

81420 88368 NCCI

81420 88369 NCCI

81420 88373 NCCI

81420 88374 NCCI

81420 88377 NCCI

81420 G0452 NCCI

81422 80500 NCCI

81422 80502 NCCI

81422 81161 NCCI

81422 81162 NCCI

81422 81170 NCCI

81422 81200 NCCI

81422 81201 NCCI

81422 81202 NCCI

81422 81203 NCCI

81422 81205 NCCI

81422 81206 NCCI

Comprehensive ComponentCode Code Source

81422 81207 NCCI

81422 81208 NCCI

81422 81209 NCCI

81422 81210 NCCI

81422 81211 NCCI

81422 81212 NCCI

81422 81213 NCCI

81422 81214 NCCI

81422 81215 NCCI

81422 81216 NCCI

81422 81217 NCCI

81422 81218 NCCI

81422 81219 NCCI

81422 81220 NCCI

81422 81221 NCCI

81422 81222 NCCI

81422 81223 NCCI

81422 81224 NCCI

81422 81225 NCCI

81422 81226 NCCI

81422 81227 NCCI

81422 81228 NCCI

81422 81229 NCCI

81422 81235 NCCI

81422 81240 NCCI

81422 81241 NCCI

81422 81242 NCCI

81422 81243 NCCI

81422 81244 NCCI

81422 81245 NCCI

81422 81246 NCCI

81422 81250 NCCI

81422 81251 NCCI

81422 81252 NCCI

81422 81253 NCCI

81422 81254 NCCI

81422 81255 NCCI

81422 81256 NCCI

81422 81257 NCCI

81422 81260 NCCI

81422 81261 NCCI

81422 81262 NCCI

81422 81263 NCCI

81422 81264 NCCI

81422 81265 NCCI

81422 81266 NCCI

81422 81267 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 166 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81422 81268 NCCI

81422 81270 NCCI

81422 81272 NCCI

81422 81273 NCCI

81422 81275 NCCI

81422 81276 NCCI

81422 81287 NCCI

81422 81288 NCCI

81422 81290 NCCI

81422 81291 NCCI

81422 81292 NCCI

81422 81293 NCCI

81422 81294 NCCI

81422 81295 NCCI

81422 81296 NCCI

81422 81297 NCCI

81422 81298 NCCI

81422 81299 NCCI

81422 81300 NCCI

81422 81301 NCCI

81422 81302 NCCI

81422 81303 NCCI

81422 81304 NCCI

81422 81310 NCCI

81422 81311 NCCI

81422 81313 NCCI

81422 81314 NCCI

81422 81315 NCCI

81422 81316 NCCI

81422 81317 NCCI

81422 81318 NCCI

81422 81319 NCCI

81422 81321 NCCI

81422 81322 NCCI

81422 81323 NCCI

81422 81324 NCCI

81422 81325 NCCI

81422 81326 NCCI

81422 81327 NCCI

81422 81330 NCCI

81422 81331 NCCI

81422 81332 NCCI

81422 81340 NCCI

81422 81341 NCCI

81422 81342 NCCI

81422 81350 NCCI

81422 81355 NCCI

Comprehensive ComponentCode Code Source

81422 81400 NCCI

81422 81401 NCCI

81422 81402 NCCI

81422 81403 NCCI

81422 81404 NCCI

81422 81405 NCCI

81422 81406 NCCI

81422 81407 NCCI

81422 81408 NCCI

81422 81493 NCCI

81422 81504 NCCI

81422 81507 NCCI

81422 81519 NCCI

81422 81525 NCCI

81422 81528 NCCI

81422 81540 NCCI

81422 81545 NCCI

81422 81595 NCCI

81422 84311 NCCI

81422 88271 NCCI

81422 88272 NCCI

81422 88273 NCCI

81422 88274 NCCI

81422 88275 NCCI

81422 88291 NCCI

81422 88364 NCCI

81422 88365 NCCI

81422 88366 NCCI

81422 88367 NCCI

81422 88368 NCCI

81422 88369 NCCI

81422 88373 NCCI

81422 88374 NCCI

81422 88377 NCCI

81422 96523 NCCI

81422 G0452 NCCI

81425 80500 NCCI

81425 80502 NCCI

81425 81161 NCCI

81425 81162 NCCI

81425 81170 NCCI

81425 81200 NCCI

81425 81201 NCCI

81425 81202 NCCI

81425 81203 NCCI

81425 81205 NCCI

81425 81206 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 167 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81425 81207 NCCI

81425 81208 NCCI

81425 81209 NCCI

81425 81210 NCCI

81425 81211 NCCI

81425 81212 NCCI

81425 81213 NCCI

81425 81214 NCCI

81425 81215 NCCI

81425 81216 NCCI

81425 81217 NCCI

81425 81218 NCCI

81425 81219 NCCI

81425 81220 NCCI

81425 81221 NCCI

81425 81222 NCCI

81425 81223 NCCI

81425 81224 NCCI

81425 81225 NCCI

81425 81226 NCCI

81425 81227 NCCI

81425 81235 NCCI

81425 81240 NCCI

81425 81241 NCCI

81425 81242 NCCI

81425 81243 NCCI

81425 81244 NCCI

81425 81245 NCCI

81425 81246 NCCI

81425 81250 NCCI

81425 81251 NCCI

81425 81252 NCCI

81425 81253 NCCI

81425 81254 NCCI

81425 81255 NCCI

81425 81256 NCCI

81425 81257 NCCI

81425 81260 NCCI

81425 81261 NCCI

81425 81262 NCCI

81425 81263 NCCI

81425 81264 NCCI

81425 81265 NCCI

81425 81266 NCCI

81425 81267 NCCI

81425 81268 NCCI

81425 81270 NCCI

Comprehensive ComponentCode Code Source

81425 81272 NCCI

81425 81273 NCCI

81425 81275 NCCI

81425 81276 NCCI

81425 81287 NCCI

81425 81288 NCCI

81425 81290 NCCI

81425 81291 NCCI

81425 81292 NCCI

81425 81293 NCCI

81425 81294 NCCI

81425 81295 NCCI

81425 81296 NCCI

81425 81297 NCCI

81425 81298 NCCI

81425 81299 NCCI

81425 81300 NCCI

81425 81301 NCCI

81425 81302 NCCI

81425 81303 NCCI

81425 81304 NCCI

81425 81310 NCCI

81425 81311 NCCI

81425 81313 NCCI

81425 81314 NCCI

81425 81315 NCCI

81425 81316 NCCI

81425 81317 NCCI

81425 81318 NCCI

81425 81319 NCCI

81425 81321 NCCI

81425 81322 NCCI

81425 81323 NCCI

81425 81324 NCCI

81425 81325 NCCI

81425 81326 NCCI

81425 81327 NCCI

81425 81330 NCCI

81425 81331 NCCI

81425 81332 NCCI

81425 81340 NCCI

81425 81341 NCCI

81425 81342 NCCI

81425 81350 NCCI

81425 81355 NCCI

81425 81400 NCCI

81425 81401 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 168 of 255

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Comprehensive ComponentCode Code Source

81425 81402 NCCI

81425 81403 NCCI

81425 81404 NCCI

81425 81405 NCCI

81425 81406 NCCI

81425 81407 NCCI

81425 81408 NCCI

81425 81493 NCCI

81425 81504 NCCI

81425 81507 NCCI

81425 81519 NCCI

81425 81525 NCCI

81425 81528 NCCI

81425 81540 NCCI

81425 81545 NCCI

81425 81595 NCCI

81425 84311 NCCI

81425 88271 NCCI

81425 88272 NCCI

81425 88273 NCCI

81425 88274 NCCI

81425 88275 NCCI

81425 88291 NCCI

81425 88364 NCCI

81425 88365 NCCI

81425 88366 NCCI

81425 88367 NCCI

81425 88368 NCCI

81425 88369 NCCI

81425 88373 NCCI

81425 88374 NCCI

81425 88377 NCCI

81425 G0452 NCCI

81426 80500 NCCI

81426 80502 NCCI

81426 81161 NCCI

81426 81162 NCCI

81426 81170 NCCI

81426 81200 NCCI

81426 81201 NCCI

81426 81202 NCCI

81426 81203 NCCI

81426 81205 NCCI

81426 81206 NCCI

81426 81207 NCCI

81426 81208 NCCI

81426 81209 NCCI

Comprehensive ComponentCode Code Source

81426 81210 NCCI

81426 81211 NCCI

81426 81212 NCCI

81426 81213 NCCI

81426 81214 NCCI

81426 81215 NCCI

81426 81216 NCCI

81426 81217 NCCI

81426 81218 NCCI

81426 81219 NCCI

81426 81220 NCCI

81426 81221 NCCI

81426 81222 NCCI

81426 81223 NCCI

81426 81224 NCCI

81426 81225 NCCI

81426 81226 NCCI

81426 81227 NCCI

81426 81235 NCCI

81426 81240 NCCI

81426 81241 NCCI

81426 81242 NCCI

81426 81243 NCCI

81426 81244 NCCI

81426 81245 NCCI

81426 81246 NCCI

81426 81250 NCCI

81426 81251 NCCI

81426 81252 NCCI

81426 81253 NCCI

81426 81254 NCCI

81426 81255 NCCI

81426 81256 NCCI

81426 81257 NCCI

81426 81260 NCCI

81426 81261 NCCI

81426 81262 NCCI

81426 81263 NCCI

81426 81264 NCCI

81426 81265 NCCI

81426 81266 NCCI

81426 81267 NCCI

81426 81268 NCCI

81426 81270 NCCI

81426 81272 NCCI

81426 81273 NCCI

81426 81275 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 169 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81426 81276 NCCI

81426 81287 NCCI

81426 81288 NCCI

81426 81290 NCCI

81426 81291 NCCI

81426 81292 NCCI

81426 81293 NCCI

81426 81294 NCCI

81426 81295 NCCI

81426 81296 NCCI

81426 81297 NCCI

81426 81298 NCCI

81426 81299 NCCI

81426 81300 NCCI

81426 81301 NCCI

81426 81302 NCCI

81426 81303 NCCI

81426 81304 NCCI

81426 81310 NCCI

81426 81311 NCCI

81426 81313 NCCI

81426 81314 NCCI

81426 81315 NCCI

81426 81316 NCCI

81426 81317 NCCI

81426 81318 NCCI

81426 81319 NCCI

81426 81321 NCCI

81426 81322 NCCI

81426 81323 NCCI

81426 81324 NCCI

81426 81325 NCCI

81426 81326 NCCI

81426 81327 NCCI

81426 81330 NCCI

81426 81331 NCCI

81426 81332 NCCI

81426 81340 NCCI

81426 81341 NCCI

81426 81342 NCCI

81426 81350 NCCI

81426 81355 NCCI

81426 81400 NCCI

81426 81401 NCCI

81426 81402 NCCI

81426 81403 NCCI

81426 81404 NCCI

Comprehensive ComponentCode Code Source

81426 81405 NCCI

81426 81406 NCCI

81426 81407 NCCI

81426 81408 NCCI

81426 81493 NCCI

81426 81504 NCCI

81426 81507 NCCI

81426 81519 NCCI

81426 81525 NCCI

81426 81528 NCCI

81426 81540 NCCI

81426 81545 NCCI

81426 81595 NCCI

81426 84311 NCCI

81426 88271 NCCI

81426 88272 NCCI

81426 88273 NCCI

81426 88274 NCCI

81426 88275 NCCI

81426 88291 NCCI

81426 88364 NCCI

81426 88365 NCCI

81426 88366 NCCI

81426 88367 NCCI

81426 88368 NCCI

81426 88369 NCCI

81426 88373 NCCI

81426 88374 NCCI

81426 88377 NCCI

81426 G0452 NCCI

81427 80500 NCCI

81427 80502 NCCI

81427 81161 NCCI

81427 81162 NCCI

81427 81170 NCCI

81427 81200 NCCI

81427 81201 NCCI

81427 81202 NCCI

81427 81203 NCCI

81427 81205 NCCI

81427 81206 NCCI

81427 81207 NCCI

81427 81208 NCCI

81427 81209 NCCI

81427 81210 NCCI

81427 81211 NCCI

81427 81212 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 170 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81427 81213 NCCI

81427 81214 NCCI

81427 81215 NCCI

81427 81216 NCCI

81427 81217 NCCI

81427 81218 NCCI

81427 81219 NCCI

81427 81220 NCCI

81427 81221 NCCI

81427 81222 NCCI

81427 81223 NCCI

81427 81224 NCCI

81427 81225 NCCI

81427 81226 NCCI

81427 81227 NCCI

81427 81235 NCCI

81427 81240 NCCI

81427 81241 NCCI

81427 81242 NCCI

81427 81243 NCCI

81427 81244 NCCI

81427 81245 NCCI

81427 81246 NCCI

81427 81250 NCCI

81427 81251 NCCI

81427 81252 NCCI

81427 81253 NCCI

81427 81254 NCCI

81427 81255 NCCI

81427 81256 NCCI

81427 81257 NCCI

81427 81260 NCCI

81427 81261 NCCI

81427 81262 NCCI

81427 81263 NCCI

81427 81264 NCCI

81427 81265 NCCI

81427 81266 NCCI

81427 81267 NCCI

81427 81268 NCCI

81427 81270 NCCI

81427 81272 NCCI

81427 81273 NCCI

81427 81275 NCCI

81427 81276 NCCI

81427 81287 NCCI

81427 81288 NCCI

Comprehensive ComponentCode Code Source

81427 81290 NCCI

81427 81291 NCCI

81427 81292 NCCI

81427 81293 NCCI

81427 81294 NCCI

81427 81295 NCCI

81427 81296 NCCI

81427 81297 NCCI

81427 81298 NCCI

81427 81299 NCCI

81427 81300 NCCI

81427 81301 NCCI

81427 81302 NCCI

81427 81303 NCCI

81427 81304 NCCI

81427 81310 NCCI

81427 81311 NCCI

81427 81313 NCCI

81427 81314 NCCI

81427 81315 NCCI

81427 81316 NCCI

81427 81317 NCCI

81427 81318 NCCI

81427 81319 NCCI

81427 81321 NCCI

81427 81322 NCCI

81427 81323 NCCI

81427 81324 NCCI

81427 81325 NCCI

81427 81326 NCCI

81427 81327 NCCI

81427 81330 NCCI

81427 81331 NCCI

81427 81332 NCCI

81427 81340 NCCI

81427 81341 NCCI

81427 81342 NCCI

81427 81350 NCCI

81427 81355 NCCI

81427 81400 NCCI

81427 81401 NCCI

81427 81402 NCCI

81427 81403 NCCI

81427 81404 NCCI

81427 81405 NCCI

81427 81406 NCCI

81427 81407 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 171 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81427 81408 NCCI

81427 81493 NCCI

81427 81504 NCCI

81427 81507 NCCI

81427 81519 NCCI

81427 81525 NCCI

81427 81528 NCCI

81427 81540 NCCI

81427 81545 NCCI

81427 81595 NCCI

81427 84311 NCCI

81427 88271 NCCI

81427 88272 NCCI

81427 88273 NCCI

81427 88274 NCCI

81427 88275 NCCI

81427 88291 NCCI

81427 88364 NCCI

81427 88365 NCCI

81427 88366 NCCI

81427 88367 NCCI

81427 88368 NCCI

81427 88369 NCCI

81427 88373 NCCI

81427 88374 NCCI

81427 88377 NCCI

81427 G0452 NCCI

81430 80500 NCCI

81430 80502 NCCI

81430 81161 NCCI

81430 81162 NCCI

81430 81170 NCCI

81430 81200 NCCI

81430 81201 NCCI

81430 81202 NCCI

81430 81203 NCCI

81430 81205 NCCI

81430 81206 NCCI

81430 81207 NCCI

81430 81208 NCCI

81430 81209 NCCI

81430 81210 NCCI

81430 81211 NCCI

81430 81212 NCCI

81430 81213 NCCI

81430 81214 NCCI

81430 81215 NCCI

Comprehensive ComponentCode Code Source

81430 81216 NCCI

81430 81217 NCCI

81430 81218 NCCI

81430 81219 NCCI

81430 81220 NCCI

81430 81221 NCCI

81430 81222 NCCI

81430 81223 NCCI

81430 81224 NCCI

81430 81225 NCCI

81430 81226 NCCI

81430 81227 NCCI

81430 81235 NCCI

81430 81240 NCCI

81430 81241 NCCI

81430 81242 NCCI

81430 81243 NCCI

81430 81244 NCCI

81430 81245 NCCI

81430 81246 NCCI

81430 81250 NCCI

81430 81251 NCCI

81430 81252 NCCI

81430 81253 NCCI

81430 81254 NCCI

81430 81255 NCCI

81430 81256 NCCI

81430 81257 NCCI

81430 81260 NCCI

81430 81261 NCCI

81430 81262 NCCI

81430 81263 NCCI

81430 81264 NCCI

81430 81265 NCCI

81430 81266 NCCI

81430 81267 NCCI

81430 81268 NCCI

81430 81270 NCCI

81430 81272 NCCI

81430 81273 NCCI

81430 81275 NCCI

81430 81276 NCCI

81430 81287 NCCI

81430 81288 NCCI

81430 81290 NCCI

81430 81291 NCCI

81430 81292 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 172 of 255

Page 173: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81430 81293 NCCI

81430 81294 NCCI

81430 81295 NCCI

81430 81296 NCCI

81430 81297 NCCI

81430 81298 NCCI

81430 81299 NCCI

81430 81300 NCCI

81430 81301 NCCI

81430 81302 NCCI

81430 81303 NCCI

81430 81304 NCCI

81430 81310 NCCI

81430 81311 NCCI

81430 81313 NCCI

81430 81314 NCCI

81430 81315 NCCI

81430 81316 NCCI

81430 81317 NCCI

81430 81318 NCCI

81430 81319 NCCI

81430 81321 NCCI

81430 81322 NCCI

81430 81323 NCCI

81430 81324 NCCI

81430 81325 NCCI

81430 81326 NCCI

81430 81327 NCCI

81430 81330 NCCI

81430 81331 NCCI

81430 81332 NCCI

81430 81340 NCCI

81430 81341 NCCI

81430 81342 NCCI

81430 81350 NCCI

81430 81355 NCCI

81430 81400 NCCI

81430 81401 NCCI

81430 81402 NCCI

81430 81403 NCCI

81430 81404 NCCI

81430 81405 NCCI

81430 81406 NCCI

81430 81407 NCCI

81430 81408 NCCI

81430 81493 NCCI

81430 81504 NCCI

Comprehensive ComponentCode Code Source

81430 81507 NCCI

81430 81519 NCCI

81430 81525 NCCI

81430 81528 NCCI

81430 81540 NCCI

81430 81545 NCCI

81430 81595 NCCI

81430 84311 NCCI

81430 88271 NCCI

81430 88272 NCCI

81430 88273 NCCI

81430 88274 NCCI

81430 88275 NCCI

81430 88291 NCCI

81430 88364 NCCI

81430 88365 NCCI

81430 88366 NCCI

81430 88367 NCCI

81430 88368 NCCI

81430 88369 NCCI

81430 88373 NCCI

81430 88374 NCCI

81430 88377 NCCI

81430 G0452 NCCI

81431 80500 NCCI

81431 80502 NCCI

81431 81161 NCCI

81431 81162 NCCI

81431 81170 NCCI

81431 81200 NCCI

81431 81201 NCCI

81431 81202 NCCI

81431 81203 NCCI

81431 81205 NCCI

81431 81206 NCCI

81431 81207 NCCI

81431 81208 NCCI

81431 81209 NCCI

81431 81210 NCCI

81431 81211 NCCI

81431 81212 NCCI

81431 81213 NCCI

81431 81214 NCCI

81431 81215 NCCI

81431 81216 NCCI

81431 81217 NCCI

81431 81218 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 173 of 255

Page 174: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81431 81219 NCCI

81431 81220 NCCI

81431 81221 NCCI

81431 81222 NCCI

81431 81223 NCCI

81431 81224 NCCI

81431 81225 NCCI

81431 81226 NCCI

81431 81227 NCCI

81431 81235 NCCI

81431 81240 NCCI

81431 81241 NCCI

81431 81242 NCCI

81431 81243 NCCI

81431 81244 NCCI

81431 81245 NCCI

81431 81246 NCCI

81431 81250 NCCI

81431 81251 NCCI

81431 81252 NCCI

81431 81253 NCCI

81431 81254 NCCI

81431 81255 NCCI

81431 81256 NCCI

81431 81257 NCCI

81431 81260 NCCI

81431 81261 NCCI

81431 81262 NCCI

81431 81263 NCCI

81431 81264 NCCI

81431 81265 NCCI

81431 81266 NCCI

81431 81267 NCCI

81431 81268 NCCI

81431 81270 NCCI

81431 81272 NCCI

81431 81273 NCCI

81431 81275 NCCI

81431 81276 NCCI

81431 81287 NCCI

81431 81288 NCCI

81431 81290 NCCI

81431 81291 NCCI

81431 81292 NCCI

81431 81293 NCCI

81431 81294 NCCI

81431 81295 NCCI

Comprehensive ComponentCode Code Source

81431 81296 NCCI

81431 81297 NCCI

81431 81298 NCCI

81431 81299 NCCI

81431 81300 NCCI

81431 81301 NCCI

81431 81302 NCCI

81431 81303 NCCI

81431 81304 NCCI

81431 81310 NCCI

81431 81311 NCCI

81431 81313 NCCI

81431 81314 NCCI

81431 81315 NCCI

81431 81316 NCCI

81431 81317 NCCI

81431 81318 NCCI

81431 81319 NCCI

81431 81321 NCCI

81431 81322 NCCI

81431 81323 NCCI

81431 81324 NCCI

81431 81325 NCCI

81431 81326 NCCI

81431 81327 NCCI

81431 81330 NCCI

81431 81331 NCCI

81431 81332 NCCI

81431 81340 NCCI

81431 81341 NCCI

81431 81342 NCCI

81431 81350 NCCI

81431 81355 NCCI

81431 81400 NCCI

81431 81401 NCCI

81431 81402 NCCI

81431 81403 NCCI

81431 81404 NCCI

81431 81405 NCCI

81431 81406 NCCI

81431 81407 NCCI

81431 81408 NCCI

81431 81493 NCCI

81431 81504 NCCI

81431 81507 NCCI

81431 81519 NCCI

81431 81525 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 174 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81431 81528 NCCI

81431 81540 NCCI

81431 81545 NCCI

81431 81595 NCCI

81431 84311 NCCI

81431 88271 NCCI

81431 88272 NCCI

81431 88273 NCCI

81431 88274 NCCI

81431 88275 NCCI

81431 88291 NCCI

81431 88364 NCCI

81431 88365 NCCI

81431 88366 NCCI

81431 88367 NCCI

81431 88368 NCCI

81431 88369 NCCI

81431 88373 NCCI

81431 88374 NCCI

81431 88377 NCCI

81431 G0452 NCCI

81432 80500 NCCI

81432 80502 NCCI

81432 81161 NCCI

81432 81162 NCCI

81432 81170 NCCI

81432 81200 NCCI

81432 81201 NCCI

81432 81202 NCCI

81432 81203 NCCI

81432 81205 NCCI

81432 81206 NCCI

81432 81207 NCCI

81432 81208 NCCI

81432 81209 NCCI

81432 81210 NCCI

81432 81211 NCCI

81432 81212 NCCI

81432 81213 NCCI

81432 81214 NCCI

81432 81215 NCCI

81432 81216 NCCI

81432 81217 NCCI

81432 81218 NCCI

81432 81219 NCCI

81432 81220 NCCI

81432 81221 NCCI

Comprehensive ComponentCode Code Source

81432 81222 NCCI

81432 81223 NCCI

81432 81224 NCCI

81432 81225 NCCI

81432 81226 NCCI

81432 81227 NCCI

81432 81235 NCCI

81432 81240 NCCI

81432 81241 NCCI

81432 81242 NCCI

81432 81243 NCCI

81432 81244 NCCI

81432 81245 NCCI

81432 81246 NCCI

81432 81250 NCCI

81432 81251 NCCI

81432 81252 NCCI

81432 81253 NCCI

81432 81254 NCCI

81432 81255 NCCI

81432 81256 NCCI

81432 81257 NCCI

81432 81260 NCCI

81432 81261 NCCI

81432 81262 NCCI

81432 81263 NCCI

81432 81264 NCCI

81432 81265 NCCI

81432 81266 NCCI

81432 81267 NCCI

81432 81268 NCCI

81432 81270 NCCI

81432 81272 NCCI

81432 81273 NCCI

81432 81275 NCCI

81432 81276 NCCI

81432 81287 NCCI

81432 81288 NCCI

81432 81290 NCCI

81432 81291 NCCI

81432 81292 NCCI

81432 81293 NCCI

81432 81294 NCCI

81432 81295 NCCI

81432 81296 NCCI

81432 81297 NCCI

81432 81298 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 175 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81432 81299 NCCI

81432 81300 NCCI

81432 81301 NCCI

81432 81302 NCCI

81432 81303 NCCI

81432 81304 NCCI

81432 81310 NCCI

81432 81311 NCCI

81432 81313 NCCI

81432 81314 NCCI

81432 81315 NCCI

81432 81316 NCCI

81432 81317 NCCI

81432 81318 NCCI

81432 81319 NCCI

81432 81321 NCCI

81432 81322 NCCI

81432 81323 NCCI

81432 81324 NCCI

81432 81325 NCCI

81432 81326 NCCI

81432 81327 NCCI

81432 81330 NCCI

81432 81331 NCCI

81432 81332 NCCI

81432 81340 NCCI

81432 81341 NCCI

81432 81342 NCCI

81432 81350 NCCI

81432 81355 NCCI

81432 81400 NCCI

81432 81401 NCCI

81432 81402 NCCI

81432 81403 NCCI

81432 81404 NCCI

81432 81405 NCCI

81432 81406 NCCI

81432 81407 NCCI

81432 81408 NCCI

81432 81493 NCCI

81432 81504 NCCI

81432 81507 NCCI

81432 81519 NCCI

81432 81525 NCCI

81432 81528 NCCI

81432 81540 NCCI

81432 81545 NCCI

Comprehensive ComponentCode Code Source

81432 81595 NCCI

81432 84311 NCCI

81432 88271 NCCI

81432 88272 NCCI

81432 88273 NCCI

81432 88274 NCCI

81432 88275 NCCI

81432 88291 NCCI

81432 88364 NCCI

81432 88365 NCCI

81432 88366 NCCI

81432 88367 NCCI

81432 88368 NCCI

81432 88369 NCCI

81432 88373 NCCI

81432 88374 NCCI

81432 88377 NCCI

81432 G0452 NCCI

81433 80500 NCCI

81433 80502 NCCI

81433 81161 NCCI

81433 81162 NCCI

81433 81170 NCCI

81433 81200 NCCI

81433 81201 NCCI

81433 81202 NCCI

81433 81203 NCCI

81433 81205 NCCI

81433 81206 NCCI

81433 81207 NCCI

81433 81208 NCCI

81433 81209 NCCI

81433 81210 NCCI

81433 81211 NCCI

81433 81212 NCCI

81433 81213 NCCI

81433 81214 NCCI

81433 81215 NCCI

81433 81216 NCCI

81433 81217 NCCI

81433 81218 NCCI

81433 81219 NCCI

81433 81220 NCCI

81433 81221 NCCI

81433 81222 NCCI

81433 81223 NCCI

81433 81224 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 176 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81433 81225 NCCI

81433 81226 NCCI

81433 81227 NCCI

81433 81235 NCCI

81433 81240 NCCI

81433 81241 NCCI

81433 81242 NCCI

81433 81243 NCCI

81433 81244 NCCI

81433 81245 NCCI

81433 81246 NCCI

81433 81250 NCCI

81433 81251 NCCI

81433 81252 NCCI

81433 81253 NCCI

81433 81254 NCCI

81433 81255 NCCI

81433 81256 NCCI

81433 81257 NCCI

81433 81260 NCCI

81433 81261 NCCI

81433 81262 NCCI

81433 81263 NCCI

81433 81264 NCCI

81433 81265 NCCI

81433 81266 NCCI

81433 81267 NCCI

81433 81268 NCCI

81433 81270 NCCI

81433 81272 NCCI

81433 81273 NCCI

81433 81275 NCCI

81433 81276 NCCI

81433 81287 NCCI

81433 81288 NCCI

81433 81290 NCCI

81433 81291 NCCI

81433 81292 NCCI

81433 81293 NCCI

81433 81294 NCCI

81433 81295 NCCI

81433 81296 NCCI

81433 81297 NCCI

81433 81298 NCCI

81433 81299 NCCI

81433 81300 NCCI

81433 81301 NCCI

Comprehensive ComponentCode Code Source

81433 81302 NCCI

81433 81303 NCCI

81433 81304 NCCI

81433 81310 NCCI

81433 81311 NCCI

81433 81313 NCCI

81433 81314 NCCI

81433 81315 NCCI

81433 81316 NCCI

81433 81317 NCCI

81433 81318 NCCI

81433 81319 NCCI

81433 81321 NCCI

81433 81322 NCCI

81433 81323 NCCI

81433 81324 NCCI

81433 81325 NCCI

81433 81326 NCCI

81433 81327 NCCI

81433 81330 NCCI

81433 81331 NCCI

81433 81332 NCCI

81433 81340 NCCI

81433 81341 NCCI

81433 81342 NCCI

81433 81350 NCCI

81433 81355 NCCI

81433 81400 NCCI

81433 81401 NCCI

81433 81402 NCCI

81433 81403 NCCI

81433 81404 NCCI

81433 81405 NCCI

81433 81406 NCCI

81433 81407 NCCI

81433 81408 NCCI

81433 81493 NCCI

81433 81504 NCCI

81433 81507 NCCI

81433 81519 NCCI

81433 81525 NCCI

81433 81528 NCCI

81433 81540 NCCI

81433 81545 NCCI

81433 81595 NCCI

81433 84311 NCCI

81433 88271 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 177 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81433 88272 NCCI

81433 88273 NCCI

81433 88274 NCCI

81433 88275 NCCI

81433 88291 NCCI

81433 88364 NCCI

81433 88365 NCCI

81433 88366 NCCI

81433 88367 NCCI

81433 88368 NCCI

81433 88369 NCCI

81433 88373 NCCI

81433 88374 NCCI

81433 88377 NCCI

81433 G0452 NCCI

81434 80500 NCCI

81434 80502 NCCI

81434 81161 NCCI

81434 81162 NCCI

81434 81170 NCCI

81434 81200 NCCI

81434 81201 NCCI

81434 81202 NCCI

81434 81203 NCCI

81434 81205 NCCI

81434 81206 NCCI

81434 81207 NCCI

81434 81208 NCCI

81434 81209 NCCI

81434 81210 NCCI

81434 81211 NCCI

81434 81212 NCCI

81434 81213 NCCI

81434 81214 NCCI

81434 81215 NCCI

81434 81216 NCCI

81434 81217 NCCI

81434 81218 NCCI

81434 81219 NCCI

81434 81220 NCCI

81434 81221 NCCI

81434 81222 NCCI

81434 81223 NCCI

81434 81224 NCCI

81434 81225 NCCI

81434 81226 NCCI

81434 81227 NCCI

Comprehensive ComponentCode Code Source

81434 81235 NCCI

81434 81240 NCCI

81434 81241 NCCI

81434 81242 NCCI

81434 81243 NCCI

81434 81244 NCCI

81434 81245 NCCI

81434 81246 NCCI

81434 81250 NCCI

81434 81251 NCCI

81434 81252 NCCI

81434 81253 NCCI

81434 81254 NCCI

81434 81255 NCCI

81434 81256 NCCI

81434 81257 NCCI

81434 81260 NCCI

81434 81261 NCCI

81434 81262 NCCI

81434 81263 NCCI

81434 81264 NCCI

81434 81265 NCCI

81434 81266 NCCI

81434 81267 NCCI

81434 81268 NCCI

81434 81270 NCCI

81434 81272 NCCI

81434 81273 NCCI

81434 81275 NCCI

81434 81276 NCCI

81434 81287 NCCI

81434 81288 NCCI

81434 81290 NCCI

81434 81291 NCCI

81434 81292 NCCI

81434 81293 NCCI

81434 81294 NCCI

81434 81295 NCCI

81434 81296 NCCI

81434 81297 NCCI

81434 81298 NCCI

81434 81299 NCCI

81434 81300 NCCI

81434 81301 NCCI

81434 81302 NCCI

81434 81303 NCCI

81434 81304 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 178 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81434 81310 NCCI

81434 81311 NCCI

81434 81313 NCCI

81434 81314 NCCI

81434 81315 NCCI

81434 81316 NCCI

81434 81317 NCCI

81434 81318 NCCI

81434 81319 NCCI

81434 81321 NCCI

81434 81322 NCCI

81434 81323 NCCI

81434 81324 NCCI

81434 81325 NCCI

81434 81326 NCCI

81434 81327 NCCI

81434 81330 NCCI

81434 81331 NCCI

81434 81332 NCCI

81434 81340 NCCI

81434 81341 NCCI

81434 81342 NCCI

81434 81350 NCCI

81434 81355 NCCI

81434 81400 NCCI

81434 81401 NCCI

81434 81402 NCCI

81434 81403 NCCI

81434 81404 NCCI

81434 81405 NCCI

81434 81406 NCCI

81434 81407 NCCI

81434 81408 NCCI

81434 81493 NCCI

81434 81504 NCCI

81434 81507 NCCI

81434 81519 NCCI

81434 81525 NCCI

81434 81528 NCCI

81434 81540 NCCI

81434 81545 NCCI

81434 81595 NCCI

81434 84311 NCCI

81434 88271 NCCI

81434 88272 NCCI

81434 88273 NCCI

81434 88274 NCCI

Comprehensive ComponentCode Code Source

81434 88275 NCCI

81434 88291 NCCI

81434 88364 NCCI

81434 88365 NCCI

81434 88366 NCCI

81434 88367 NCCI

81434 88368 NCCI

81434 88369 NCCI

81434 88373 NCCI

81434 88374 NCCI

81434 88377 NCCI

81434 G0452 NCCI

81435 80500 NCCI

81435 80502 NCCI

81435 81161 NCCI

81435 81162 NCCI

81435 81170 NCCI

81435 81200 NCCI

81435 81201 NCCI

81435 81202 NCCI

81435 81203 NCCI

81435 81205 NCCI

81435 81206 NCCI

81435 81207 NCCI

81435 81208 NCCI

81435 81209 NCCI

81435 81210 NCCI

81435 81211 NCCI

81435 81212 NCCI

81435 81213 NCCI

81435 81214 NCCI

81435 81215 NCCI

81435 81216 NCCI

81435 81217 NCCI

81435 81218 NCCI

81435 81219 NCCI

81435 81220 NCCI

81435 81221 NCCI

81435 81222 NCCI

81435 81223 NCCI

81435 81224 NCCI

81435 81225 NCCI

81435 81226 NCCI

81435 81227 NCCI

81435 81235 NCCI

81435 81240 NCCI

81435 81241 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 179 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81435 81242 NCCI

81435 81243 NCCI

81435 81244 NCCI

81435 81245 NCCI

81435 81246 NCCI

81435 81250 NCCI

81435 81251 NCCI

81435 81252 NCCI

81435 81253 NCCI

81435 81254 NCCI

81435 81255 NCCI

81435 81256 NCCI

81435 81257 NCCI

81435 81260 NCCI

81435 81261 NCCI

81435 81262 NCCI

81435 81263 NCCI

81435 81264 NCCI

81435 81265 NCCI

81435 81266 NCCI

81435 81267 NCCI

81435 81268 NCCI

81435 81270 NCCI

81435 81272 NCCI

81435 81273 NCCI

81435 81275 NCCI

81435 81276 NCCI

81435 81287 NCCI

81435 81288 NCCI

81435 81290 NCCI

81435 81291 NCCI

81435 81292 NCCI

81435 81293 NCCI

81435 81294 NCCI

81435 81295 NCCI

81435 81296 NCCI

81435 81297 NCCI

81435 81298 NCCI

81435 81299 NCCI

81435 81300 NCCI

81435 81301 NCCI

81435 81302 NCCI

81435 81303 NCCI

81435 81304 NCCI

81435 81310 NCCI

81435 81311 NCCI

81435 81313 NCCI

Comprehensive ComponentCode Code Source

81435 81314 NCCI

81435 81315 NCCI

81435 81316 NCCI

81435 81317 NCCI

81435 81318 NCCI

81435 81319 NCCI

81435 81321 NCCI

81435 81322 NCCI

81435 81323 NCCI

81435 81324 NCCI

81435 81325 NCCI

81435 81326 NCCI

81435 81327 NCCI

81435 81330 NCCI

81435 81331 NCCI

81435 81332 NCCI

81435 81340 NCCI

81435 81341 NCCI

81435 81342 NCCI

81435 81350 NCCI

81435 81355 NCCI

81435 81400 NCCI

81435 81401 NCCI

81435 81402 NCCI

81435 81403 NCCI

81435 81404 NCCI

81435 81405 NCCI

81435 81406 NCCI

81435 81407 NCCI

81435 81408 NCCI

81435 81493 NCCI

81435 81504 NCCI

81435 81507 NCCI

81435 81519 NCCI

81435 81525 NCCI

81435 81528 NCCI

81435 81540 NCCI

81435 81545 NCCI

81435 81595 NCCI

81435 84311 NCCI

81435 88271 NCCI

81435 88272 NCCI

81435 88273 NCCI

81435 88274 NCCI

81435 88275 NCCI

81435 88291 NCCI

81435 88364 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 180 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81435 88365 NCCI

81435 88366 NCCI

81435 88367 NCCI

81435 88368 NCCI

81435 88369 NCCI

81435 88373 NCCI

81435 88374 NCCI

81435 88377 NCCI

81435 G0452 NCCI

81436 80500 NCCI

81436 80502 NCCI

81436 81161 NCCI

81436 81162 NCCI

81436 81170 NCCI

81436 81200 NCCI

81436 81201 NCCI

81436 81202 NCCI

81436 81203 NCCI

81436 81205 NCCI

81436 81206 NCCI

81436 81207 NCCI

81436 81208 NCCI

81436 81209 NCCI

81436 81210 NCCI

81436 81211 NCCI

81436 81212 NCCI

81436 81213 NCCI

81436 81214 NCCI

81436 81215 NCCI

81436 81216 NCCI

81436 81217 NCCI

81436 81218 NCCI

81436 81219 NCCI

81436 81220 NCCI

81436 81221 NCCI

81436 81222 NCCI

81436 81223 NCCI

81436 81224 NCCI

81436 81225 NCCI

81436 81226 NCCI

81436 81227 NCCI

81436 81235 NCCI

81436 81240 NCCI

81436 81241 NCCI

81436 81242 NCCI

81436 81243 NCCI

81436 81244 NCCI

Comprehensive ComponentCode Code Source

81436 81245 NCCI

81436 81246 NCCI

81436 81250 NCCI

81436 81251 NCCI

81436 81252 NCCI

81436 81253 NCCI

81436 81254 NCCI

81436 81255 NCCI

81436 81256 NCCI

81436 81257 NCCI

81436 81260 NCCI

81436 81261 NCCI

81436 81262 NCCI

81436 81263 NCCI

81436 81264 NCCI

81436 81265 NCCI

81436 81266 NCCI

81436 81267 NCCI

81436 81268 NCCI

81436 81270 NCCI

81436 81272 NCCI

81436 81273 NCCI

81436 81275 NCCI

81436 81276 NCCI

81436 81287 NCCI

81436 81288 NCCI

81436 81290 NCCI

81436 81291 NCCI

81436 81292 NCCI

81436 81293 NCCI

81436 81294 NCCI

81436 81295 NCCI

81436 81296 NCCI

81436 81297 NCCI

81436 81298 NCCI

81436 81299 NCCI

81436 81300 NCCI

81436 81301 NCCI

81436 81302 NCCI

81436 81303 NCCI

81436 81304 NCCI

81436 81310 NCCI

81436 81311 NCCI

81436 81313 NCCI

81436 81314 NCCI

81436 81315 NCCI

81436 81316 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 181 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81436 81317 NCCI

81436 81318 NCCI

81436 81319 NCCI

81436 81321 NCCI

81436 81322 NCCI

81436 81323 NCCI

81436 81324 NCCI

81436 81325 NCCI

81436 81326 NCCI

81436 81327 NCCI

81436 81330 NCCI

81436 81331 NCCI

81436 81332 NCCI

81436 81340 NCCI

81436 81341 NCCI

81436 81342 NCCI

81436 81350 NCCI

81436 81355 NCCI

81436 81400 NCCI

81436 81401 NCCI

81436 81402 NCCI

81436 81403 NCCI

81436 81404 NCCI

81436 81405 NCCI

81436 81406 NCCI

81436 81407 NCCI

81436 81408 NCCI

81436 81493 NCCI

81436 81504 NCCI

81436 81507 NCCI

81436 81519 NCCI

81436 81525 NCCI

81436 81528 NCCI

81436 81540 NCCI

81436 81545 NCCI

81436 81595 NCCI

81436 84311 NCCI

81436 88271 NCCI

81436 88272 NCCI

81436 88273 NCCI

81436 88274 NCCI

81436 88275 NCCI

81436 88291 NCCI

81436 88364 NCCI

81436 88365 NCCI

81436 88366 NCCI

81436 88367 NCCI

Comprehensive ComponentCode Code Source

81436 88368 NCCI

81436 88369 NCCI

81436 88373 NCCI

81436 88374 NCCI

81436 88377 NCCI

81436 G0452 NCCI

81437 80500 NCCI

81437 80502 NCCI

81437 81161 NCCI

81437 81162 NCCI

81437 81170 NCCI

81437 81200 NCCI

81437 81201 NCCI

81437 81202 NCCI

81437 81203 NCCI

81437 81205 NCCI

81437 81206 NCCI

81437 81207 NCCI

81437 81208 NCCI

81437 81209 NCCI

81437 81210 NCCI

81437 81211 NCCI

81437 81212 NCCI

81437 81213 NCCI

81437 81214 NCCI

81437 81215 NCCI

81437 81216 NCCI

81437 81217 NCCI

81437 81218 NCCI

81437 81219 NCCI

81437 81220 NCCI

81437 81221 NCCI

81437 81222 NCCI

81437 81223 NCCI

81437 81224 NCCI

81437 81225 NCCI

81437 81226 NCCI

81437 81227 NCCI

81437 81235 NCCI

81437 81240 NCCI

81437 81241 NCCI

81437 81242 NCCI

81437 81243 NCCI

81437 81244 NCCI

81437 81245 NCCI

81437 81246 NCCI

81437 81250 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 182 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81437 81251 NCCI

81437 81252 NCCI

81437 81253 NCCI

81437 81254 NCCI

81437 81255 NCCI

81437 81256 NCCI

81437 81257 NCCI

81437 81260 NCCI

81437 81261 NCCI

81437 81262 NCCI

81437 81263 NCCI

81437 81264 NCCI

81437 81265 NCCI

81437 81266 NCCI

81437 81267 NCCI

81437 81268 NCCI

81437 81270 NCCI

81437 81272 NCCI

81437 81273 NCCI

81437 81275 NCCI

81437 81276 NCCI

81437 81287 NCCI

81437 81288 NCCI

81437 81290 NCCI

81437 81291 NCCI

81437 81292 NCCI

81437 81293 NCCI

81437 81294 NCCI

81437 81295 NCCI

81437 81296 NCCI

81437 81297 NCCI

81437 81298 NCCI

81437 81299 NCCI

81437 81300 NCCI

81437 81301 NCCI

81437 81302 NCCI

81437 81303 NCCI

81437 81304 NCCI

81437 81310 NCCI

81437 81311 NCCI

81437 81313 NCCI

81437 81314 NCCI

81437 81315 NCCI

81437 81316 NCCI

81437 81317 NCCI

81437 81318 NCCI

81437 81319 NCCI

Comprehensive ComponentCode Code Source

81437 81321 NCCI

81437 81322 NCCI

81437 81323 NCCI

81437 81324 NCCI

81437 81325 NCCI

81437 81326 NCCI

81437 81327 NCCI

81437 81330 NCCI

81437 81331 NCCI

81437 81332 NCCI

81437 81340 NCCI

81437 81341 NCCI

81437 81342 NCCI

81437 81350 NCCI

81437 81355 NCCI

81437 81400 NCCI

81437 81401 NCCI

81437 81402 NCCI

81437 81403 NCCI

81437 81404 NCCI

81437 81405 NCCI

81437 81406 NCCI

81437 81407 NCCI

81437 81408 NCCI

81437 81493 NCCI

81437 81504 NCCI

81437 81507 NCCI

81437 81519 NCCI

81437 81525 NCCI

81437 81528 NCCI

81437 81540 NCCI

81437 81545 NCCI

81437 81595 NCCI

81437 84311 NCCI

81437 88271 NCCI

81437 88272 NCCI

81437 88273 NCCI

81437 88274 NCCI

81437 88275 NCCI

81437 88291 NCCI

81437 88364 NCCI

81437 88365 NCCI

81437 88366 NCCI

81437 88367 NCCI

81437 88368 NCCI

81437 88369 NCCI

81437 88373 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 183 of 255

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Comprehensive ComponentCode Code Source

81437 88374 NCCI

81437 88377 NCCI

81437 G0452 NCCI

81438 80500 NCCI

81438 80502 NCCI

81438 81161 NCCI

81438 81162 NCCI

81438 81170 NCCI

81438 81200 NCCI

81438 81201 NCCI

81438 81202 NCCI

81438 81203 NCCI

81438 81205 NCCI

81438 81206 NCCI

81438 81207 NCCI

81438 81208 NCCI

81438 81209 NCCI

81438 81210 NCCI

81438 81211 NCCI

81438 81212 NCCI

81438 81213 NCCI

81438 81214 NCCI

81438 81215 NCCI

81438 81216 NCCI

81438 81217 NCCI

81438 81218 NCCI

81438 81219 NCCI

81438 81220 NCCI

81438 81221 NCCI

81438 81222 NCCI

81438 81223 NCCI

81438 81224 NCCI

81438 81225 NCCI

81438 81226 NCCI

81438 81227 NCCI

81438 81235 NCCI

81438 81240 NCCI

81438 81241 NCCI

81438 81242 NCCI

81438 81243 NCCI

81438 81244 NCCI

81438 81245 NCCI

81438 81246 NCCI

81438 81250 NCCI

81438 81251 NCCI

81438 81252 NCCI

81438 81253 NCCI

Comprehensive ComponentCode Code Source

81438 81254 NCCI

81438 81255 NCCI

81438 81256 NCCI

81438 81257 NCCI

81438 81260 NCCI

81438 81261 NCCI

81438 81262 NCCI

81438 81263 NCCI

81438 81264 NCCI

81438 81265 NCCI

81438 81266 NCCI

81438 81267 NCCI

81438 81268 NCCI

81438 81270 NCCI

81438 81272 NCCI

81438 81273 NCCI

81438 81275 NCCI

81438 81276 NCCI

81438 81287 NCCI

81438 81288 NCCI

81438 81290 NCCI

81438 81291 NCCI

81438 81292 NCCI

81438 81293 NCCI

81438 81294 NCCI

81438 81295 NCCI

81438 81296 NCCI

81438 81297 NCCI

81438 81298 NCCI

81438 81299 NCCI

81438 81300 NCCI

81438 81301 NCCI

81438 81302 NCCI

81438 81303 NCCI

81438 81304 NCCI

81438 81310 NCCI

81438 81311 NCCI

81438 81313 NCCI

81438 81314 NCCI

81438 81315 NCCI

81438 81316 NCCI

81438 81317 NCCI

81438 81318 NCCI

81438 81319 NCCI

81438 81321 NCCI

81438 81322 NCCI

81438 81323 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 184 of 255

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Comprehensive ComponentCode Code Source

81438 81324 NCCI

81438 81325 NCCI

81438 81326 NCCI

81438 81327 NCCI

81438 81330 NCCI

81438 81331 NCCI

81438 81332 NCCI

81438 81340 NCCI

81438 81341 NCCI

81438 81342 NCCI

81438 81350 NCCI

81438 81355 NCCI

81438 81400 NCCI

81438 81401 NCCI

81438 81402 NCCI

81438 81403 NCCI

81438 81404 NCCI

81438 81405 NCCI

81438 81406 NCCI

81438 81407 NCCI

81438 81408 NCCI

81438 81493 NCCI

81438 81504 NCCI

81438 81507 NCCI

81438 81519 NCCI

81438 81525 NCCI

81438 81528 NCCI

81438 81540 NCCI

81438 81545 NCCI

81438 81595 NCCI

81438 84311 NCCI

81438 88271 NCCI

81438 88272 NCCI

81438 88273 NCCI

81438 88274 NCCI

81438 88275 NCCI

81438 88291 NCCI

81438 88364 NCCI

81438 88365 NCCI

81438 88366 NCCI

81438 88367 NCCI

81438 88368 NCCI

81438 88369 NCCI

81438 88373 NCCI

81438 88374 NCCI

81438 88377 NCCI

81438 G0452 NCCI

Comprehensive ComponentCode Code Source

81439 80500 NCCI

81439 80502 NCCI

81439 81161 NCCI

81439 81162 NCCI

81439 81170 NCCI

81439 81200 NCCI

81439 81201 NCCI

81439 81202 NCCI

81439 81203 NCCI

81439 81205 NCCI

81439 81206 NCCI

81439 81207 NCCI

81439 81208 NCCI

81439 81209 NCCI

81439 81210 NCCI

81439 81211 NCCI

81439 81212 NCCI

81439 81213 NCCI

81439 81214 NCCI

81439 81215 NCCI

81439 81216 NCCI

81439 81217 NCCI

81439 81218 NCCI

81439 81219 NCCI

81439 81220 NCCI

81439 81221 NCCI

81439 81222 NCCI

81439 81223 NCCI

81439 81224 NCCI

81439 81225 NCCI

81439 81226 NCCI

81439 81227 NCCI

81439 81228 NCCI

81439 81229 NCCI

81439 81235 NCCI

81439 81240 NCCI

81439 81241 NCCI

81439 81242 NCCI

81439 81243 NCCI

81439 81244 NCCI

81439 81245 NCCI

81439 81246 NCCI

81439 81250 NCCI

81439 81251 NCCI

81439 81252 NCCI

81439 81253 NCCI

81439 81254 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 185 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81439 81255 NCCI

81439 81256 NCCI

81439 81257 NCCI

81439 81260 NCCI

81439 81261 NCCI

81439 81262 NCCI

81439 81263 NCCI

81439 81264 NCCI

81439 81265 NCCI

81439 81266 NCCI

81439 81267 NCCI

81439 81268 NCCI

81439 81270 NCCI

81439 81272 NCCI

81439 81273 NCCI

81439 81275 NCCI

81439 81276 NCCI

81439 81287 NCCI

81439 81288 NCCI

81439 81290 NCCI

81439 81291 NCCI

81439 81292 NCCI

81439 81293 NCCI

81439 81294 NCCI

81439 81295 NCCI

81439 81296 NCCI

81439 81297 NCCI

81439 81298 NCCI

81439 81299 NCCI

81439 81300 NCCI

81439 81301 NCCI

81439 81302 NCCI

81439 81303 NCCI

81439 81304 NCCI

81439 81310 NCCI

81439 81311 NCCI

81439 81313 NCCI

81439 81314 NCCI

81439 81315 NCCI

81439 81316 NCCI

81439 81317 NCCI

81439 81318 NCCI

81439 81319 NCCI

81439 81321 NCCI

81439 81322 NCCI

81439 81323 NCCI

81439 81324 NCCI

Comprehensive ComponentCode Code Source

81439 81325 NCCI

81439 81326 NCCI

81439 81327 NCCI

81439 81330 NCCI

81439 81331 NCCI

81439 81332 NCCI

81439 81340 NCCI

81439 81341 NCCI

81439 81342 NCCI

81439 81350 NCCI

81439 81355 NCCI

81439 81400 NCCI

81439 81401 NCCI

81439 81402 NCCI

81439 81403 NCCI

81439 81404 NCCI

81439 81405 NCCI

81439 81406 NCCI

81439 81407 NCCI

81439 81408 NCCI

81439 81413 NCCI

81439 81414 NCCI

81439 81493 NCCI

81439 81504 NCCI

81439 81507 NCCI

81439 81519 NCCI

81439 81525 NCCI

81439 81528 NCCI

81439 81540 NCCI

81439 81545 NCCI

81439 81595 NCCI

81439 84311 NCCI

81439 88271 NCCI

81439 88272 NCCI

81439 88273 NCCI

81439 88274 NCCI

81439 88275 NCCI

81439 88291 NCCI

81439 88364 NCCI

81439 88365 NCCI

81439 88366 NCCI

81439 88367 NCCI

81439 88368 NCCI

81439 88369 NCCI

81439 88373 NCCI

81439 88374 NCCI

81439 88377 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 186 of 255

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Comprehensive ComponentCode Code Source

81439 96523 NCCI

81439 G0452 NCCI

81440 80500 NCCI

81440 80502 NCCI

81440 81161 NCCI

81440 81162 NCCI

81440 81170 NCCI

81440 81200 NCCI

81440 81201 NCCI

81440 81202 NCCI

81440 81203 NCCI

81440 81205 NCCI

81440 81206 NCCI

81440 81207 NCCI

81440 81208 NCCI

81440 81209 NCCI

81440 81210 NCCI

81440 81211 NCCI

81440 81212 NCCI

81440 81213 NCCI

81440 81214 NCCI

81440 81215 NCCI

81440 81216 NCCI

81440 81217 NCCI

81440 81218 NCCI

81440 81219 NCCI

81440 81220 NCCI

81440 81221 NCCI

81440 81222 NCCI

81440 81223 NCCI

81440 81224 NCCI

81440 81225 NCCI

81440 81226 NCCI

81440 81227 NCCI

81440 81235 NCCI

81440 81240 NCCI

81440 81241 NCCI

81440 81242 NCCI

81440 81243 NCCI

81440 81244 NCCI

81440 81245 NCCI

81440 81246 NCCI

81440 81250 NCCI

81440 81251 NCCI

81440 81252 NCCI

81440 81253 NCCI

81440 81254 NCCI

Comprehensive ComponentCode Code Source

81440 81255 NCCI

81440 81256 NCCI

81440 81257 NCCI

81440 81260 NCCI

81440 81261 NCCI

81440 81262 NCCI

81440 81263 NCCI

81440 81264 NCCI

81440 81265 NCCI

81440 81266 NCCI

81440 81267 NCCI

81440 81268 NCCI

81440 81270 NCCI

81440 81272 NCCI

81440 81273 NCCI

81440 81275 NCCI

81440 81276 NCCI

81440 81287 NCCI

81440 81288 NCCI

81440 81290 NCCI

81440 81291 NCCI

81440 81292 NCCI

81440 81293 NCCI

81440 81294 NCCI

81440 81295 NCCI

81440 81296 NCCI

81440 81297 NCCI

81440 81298 NCCI

81440 81299 NCCI

81440 81300 NCCI

81440 81301 NCCI

81440 81302 NCCI

81440 81303 NCCI

81440 81304 NCCI

81440 81310 NCCI

81440 81311 NCCI

81440 81313 NCCI

81440 81314 NCCI

81440 81315 NCCI

81440 81316 NCCI

81440 81317 NCCI

81440 81318 NCCI

81440 81319 NCCI

81440 81321 NCCI

81440 81322 NCCI

81440 81323 NCCI

81440 81324 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 187 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81440 81325 NCCI

81440 81326 NCCI

81440 81327 NCCI

81440 81330 NCCI

81440 81331 NCCI

81440 81332 NCCI

81440 81340 NCCI

81440 81341 NCCI

81440 81342 NCCI

81440 81350 NCCI

81440 81355 NCCI

81440 81400 NCCI

81440 81401 NCCI

81440 81402 NCCI

81440 81403 NCCI

81440 81404 NCCI

81440 81405 NCCI

81440 81406 NCCI

81440 81407 NCCI

81440 81408 NCCI

81440 81493 NCCI

81440 81504 NCCI

81440 81507 NCCI

81440 81519 NCCI

81440 81525 NCCI

81440 81528 NCCI

81440 81540 NCCI

81440 81545 NCCI

81440 81595 NCCI

81440 84311 NCCI

81440 88271 NCCI

81440 88272 NCCI

81440 88273 NCCI

81440 88274 NCCI

81440 88275 NCCI

81440 88291 NCCI

81440 88364 NCCI

81440 88365 NCCI

81440 88366 NCCI

81440 88367 NCCI

81440 88368 NCCI

81440 88369 NCCI

81440 88373 NCCI

81440 88374 NCCI

81440 88377 NCCI

81440 G0452 NCCI

81442 80500 NCCI

Comprehensive ComponentCode Code Source

81442 80502 NCCI

81442 81161 NCCI

81442 81162 NCCI

81442 81170 NCCI

81442 81200 NCCI

81442 81201 NCCI

81442 81202 NCCI

81442 81203 NCCI

81442 81205 NCCI

81442 81206 NCCI

81442 81207 NCCI

81442 81208 NCCI

81442 81209 NCCI

81442 81210 NCCI

81442 81211 NCCI

81442 81212 NCCI

81442 81213 NCCI

81442 81214 NCCI

81442 81215 NCCI

81442 81216 NCCI

81442 81217 NCCI

81442 81218 NCCI

81442 81219 NCCI

81442 81220 NCCI

81442 81221 NCCI

81442 81222 NCCI

81442 81223 NCCI

81442 81224 NCCI

81442 81225 NCCI

81442 81226 NCCI

81442 81227 NCCI

81442 81235 NCCI

81442 81240 NCCI

81442 81241 NCCI

81442 81242 NCCI

81442 81243 NCCI

81442 81244 NCCI

81442 81245 NCCI

81442 81246 NCCI

81442 81250 NCCI

81442 81251 NCCI

81442 81252 NCCI

81442 81253 NCCI

81442 81254 NCCI

81442 81255 NCCI

81442 81256 NCCI

81442 81257 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 188 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81442 81260 NCCI

81442 81261 NCCI

81442 81262 NCCI

81442 81263 NCCI

81442 81264 NCCI

81442 81265 NCCI

81442 81266 NCCI

81442 81267 NCCI

81442 81268 NCCI

81442 81270 NCCI

81442 81272 NCCI

81442 81273 NCCI

81442 81275 NCCI

81442 81276 NCCI

81442 81287 NCCI

81442 81288 NCCI

81442 81290 NCCI

81442 81291 NCCI

81442 81292 NCCI

81442 81293 NCCI

81442 81294 NCCI

81442 81295 NCCI

81442 81296 NCCI

81442 81297 NCCI

81442 81298 NCCI

81442 81299 NCCI

81442 81300 NCCI

81442 81301 NCCI

81442 81302 NCCI

81442 81303 NCCI

81442 81304 NCCI

81442 81310 NCCI

81442 81311 NCCI

81442 81313 NCCI

81442 81314 NCCI

81442 81315 NCCI

81442 81316 NCCI

81442 81317 NCCI

81442 81318 NCCI

81442 81319 NCCI

81442 81321 NCCI

81442 81322 NCCI

81442 81323 NCCI

81442 81324 NCCI

81442 81325 NCCI

81442 81326 NCCI

81442 81327 NCCI

Comprehensive ComponentCode Code Source

81442 81330 NCCI

81442 81331 NCCI

81442 81332 NCCI

81442 81340 NCCI

81442 81341 NCCI

81442 81342 NCCI

81442 81350 NCCI

81442 81355 NCCI

81442 81400 NCCI

81442 81401 NCCI

81442 81402 NCCI

81442 81403 NCCI

81442 81404 NCCI

81442 81405 NCCI

81442 81406 NCCI

81442 81407 NCCI

81442 81408 NCCI

81442 81493 NCCI

81442 81504 NCCI

81442 81507 NCCI

81442 81519 NCCI

81442 81525 NCCI

81442 81528 NCCI

81442 81540 NCCI

81442 81545 NCCI

81442 81595 NCCI

81442 84311 NCCI

81442 88271 NCCI

81442 88272 NCCI

81442 88273 NCCI

81442 88274 NCCI

81442 88275 NCCI

81442 88291 NCCI

81442 88364 NCCI

81442 88365 NCCI

81442 88366 NCCI

81442 88367 NCCI

81442 88368 NCCI

81442 88369 NCCI

81442 88373 NCCI

81442 88374 NCCI

81442 88377 NCCI

81442 G0452 NCCI

81445 80500 NCCI

81445 80502 NCCI

81445 81161 NCCI

81445 81162 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 189 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81445 81170 NCCI

81445 81200 NCCI

81445 81201 NCCI

81445 81202 NCCI

81445 81203 NCCI

81445 81205 NCCI

81445 81206 NCCI

81445 81207 NCCI

81445 81208 NCCI

81445 81209 NCCI

81445 81210 NCCI

81445 81211 NCCI

81445 81212 NCCI

81445 81213 NCCI

81445 81214 NCCI

81445 81215 NCCI

81445 81216 NCCI

81445 81217 NCCI

81445 81218 NCCI

81445 81219 NCCI

81445 81220 NCCI

81445 81221 NCCI

81445 81222 NCCI

81445 81223 NCCI

81445 81224 NCCI

81445 81225 NCCI

81445 81226 NCCI

81445 81227 NCCI

81445 81235 NCCI

81445 81240 NCCI

81445 81241 NCCI

81445 81242 NCCI

81445 81243 NCCI

81445 81244 NCCI

81445 81245 NCCI

81445 81246 NCCI

81445 81250 NCCI

81445 81251 NCCI

81445 81252 NCCI

81445 81253 NCCI

81445 81254 NCCI

81445 81255 NCCI

81445 81256 NCCI

81445 81257 NCCI

81445 81260 NCCI

81445 81261 NCCI

81445 81262 NCCI

Comprehensive ComponentCode Code Source

81445 81263 NCCI

81445 81264 NCCI

81445 81265 NCCI

81445 81266 NCCI

81445 81267 NCCI

81445 81268 NCCI

81445 81270 NCCI

81445 81272 NCCI

81445 81273 NCCI

81445 81275 NCCI

81445 81276 NCCI

81445 81287 NCCI

81445 81288 NCCI

81445 81290 NCCI

81445 81291 NCCI

81445 81292 NCCI

81445 81293 NCCI

81445 81294 NCCI

81445 81295 NCCI

81445 81296 NCCI

81445 81297 NCCI

81445 81298 NCCI

81445 81299 NCCI

81445 81300 NCCI

81445 81301 NCCI

81445 81302 NCCI

81445 81303 NCCI

81445 81304 NCCI

81445 81310 NCCI

81445 81311 NCCI

81445 81313 NCCI

81445 81314 NCCI

81445 81315 NCCI

81445 81316 NCCI

81445 81317 NCCI

81445 81318 NCCI

81445 81319 NCCI

81445 81321 NCCI

81445 81322 NCCI

81445 81323 NCCI

81445 81324 NCCI

81445 81325 NCCI

81445 81326 NCCI

81445 81327 NCCI

81445 81330 NCCI

81445 81331 NCCI

81445 81332 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 190 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81445 81340 NCCI

81445 81341 NCCI

81445 81342 NCCI

81445 81350 NCCI

81445 81355 NCCI

81445 81400 NCCI

81445 81401 NCCI

81445 81402 NCCI

81445 81403 NCCI

81445 81404 NCCI

81445 81405 NCCI

81445 81406 NCCI

81445 81407 NCCI

81445 81408 NCCI

81445 81493 NCCI

81445 81504 NCCI

81445 81507 NCCI

81445 81519 NCCI

81445 81525 NCCI

81445 81528 NCCI

81445 81540 NCCI

81445 81545 NCCI

81445 81595 NCCI

81445 84311 NCCI

81445 88271 NCCI

81445 88272 NCCI

81445 88273 NCCI

81445 88274 NCCI

81445 88275 NCCI

81445 88291 NCCI

81445 88364 NCCI

81445 88365 NCCI

81445 88366 NCCI

81445 88367 NCCI

81445 88368 NCCI

81445 88369 NCCI

81445 88373 NCCI

81445 88374 NCCI

81445 88377 NCCI

81445 G0452 NCCI

81450 80500 NCCI

81450 80502 NCCI

81450 81161 NCCI

81450 81162 NCCI

81450 81170 NCCI

81450 81200 NCCI

81450 81201 NCCI

Comprehensive ComponentCode Code Source

81450 81202 NCCI

81450 81203 NCCI

81450 81205 NCCI

81450 81206 NCCI

81450 81207 NCCI

81450 81208 NCCI

81450 81209 NCCI

81450 81210 NCCI

81450 81211 NCCI

81450 81212 NCCI

81450 81213 NCCI

81450 81214 NCCI

81450 81215 NCCI

81450 81216 NCCI

81450 81217 NCCI

81450 81218 NCCI

81450 81219 NCCI

81450 81220 NCCI

81450 81221 NCCI

81450 81222 NCCI

81450 81223 NCCI

81450 81224 NCCI

81450 81225 NCCI

81450 81226 NCCI

81450 81227 NCCI

81450 81235 NCCI

81450 81240 NCCI

81450 81241 NCCI

81450 81242 NCCI

81450 81243 NCCI

81450 81244 NCCI

81450 81245 NCCI

81450 81246 NCCI

81450 81250 NCCI

81450 81251 NCCI

81450 81252 NCCI

81450 81253 NCCI

81450 81254 NCCI

81450 81255 NCCI

81450 81256 NCCI

81450 81257 NCCI

81450 81260 NCCI

81450 81261 NCCI

81450 81262 NCCI

81450 81263 NCCI

81450 81264 NCCI

81450 81265 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 191 of 255

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Comprehensive ComponentCode Code Source

81450 81266 NCCI

81450 81267 NCCI

81450 81268 NCCI

81450 81270 NCCI

81450 81272 NCCI

81450 81273 NCCI

81450 81275 NCCI

81450 81276 NCCI

81450 81287 NCCI

81450 81288 NCCI

81450 81290 NCCI

81450 81291 NCCI

81450 81292 NCCI

81450 81293 NCCI

81450 81294 NCCI

81450 81295 NCCI

81450 81296 NCCI

81450 81297 NCCI

81450 81298 NCCI

81450 81299 NCCI

81450 81300 NCCI

81450 81301 NCCI

81450 81302 NCCI

81450 81303 NCCI

81450 81304 NCCI

81450 81310 NCCI

81450 81311 NCCI

81450 81313 NCCI

81450 81314 NCCI

81450 81315 NCCI

81450 81316 NCCI

81450 81317 NCCI

81450 81318 NCCI

81450 81319 NCCI

81450 81321 NCCI

81450 81322 NCCI

81450 81323 NCCI

81450 81324 NCCI

81450 81325 NCCI

81450 81326 NCCI

81450 81327 NCCI

81450 81330 NCCI

81450 81331 NCCI

81450 81332 NCCI

81450 81340 NCCI

81450 81341 NCCI

81450 81342 NCCI

Comprehensive ComponentCode Code Source

81450 81350 NCCI

81450 81355 NCCI

81450 81400 NCCI

81450 81401 NCCI

81450 81402 NCCI

81450 81403 NCCI

81450 81404 NCCI

81450 81405 NCCI

81450 81406 NCCI

81450 81407 NCCI

81450 81408 NCCI

81450 81445 NCCI

81450 81493 NCCI

81450 81504 NCCI

81450 81507 NCCI

81450 81519 NCCI

81450 81525 NCCI

81450 81528 NCCI

81450 81540 NCCI

81450 81545 NCCI

81450 81595 NCCI

81450 84311 NCCI

81450 88271 NCCI

81450 88272 NCCI

81450 88273 NCCI

81450 88274 NCCI

81450 88275 NCCI

81450 88291 NCCI

81450 88364 NCCI

81450 88365 NCCI

81450 88366 NCCI

81450 88367 NCCI

81450 88368 NCCI

81450 88369 NCCI

81450 88373 NCCI

81450 88374 NCCI

81450 88377 NCCI

81450 G0452 NCCI

81455 80500 NCCI

81455 80502 NCCI

81455 81161 NCCI

81455 81162 NCCI

81455 81170 NCCI

81455 81200 NCCI

81455 81201 NCCI

81455 81202 NCCI

81455 81203 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 192 of 255

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Comprehensive ComponentCode Code Source

81455 81205 NCCI

81455 81206 NCCI

81455 81207 NCCI

81455 81208 NCCI

81455 81209 NCCI

81455 81210 NCCI

81455 81211 NCCI

81455 81212 NCCI

81455 81213 NCCI

81455 81214 NCCI

81455 81215 NCCI

81455 81216 NCCI

81455 81217 NCCI

81455 81218 NCCI

81455 81219 NCCI

81455 81220 NCCI

81455 81221 NCCI

81455 81222 NCCI

81455 81223 NCCI

81455 81224 NCCI

81455 81225 NCCI

81455 81226 NCCI

81455 81227 NCCI

81455 81235 NCCI

81455 81240 NCCI

81455 81241 NCCI

81455 81242 NCCI

81455 81243 NCCI

81455 81244 NCCI

81455 81245 NCCI

81455 81246 NCCI

81455 81250 NCCI

81455 81251 NCCI

81455 81252 NCCI

81455 81253 NCCI

81455 81254 NCCI

81455 81255 NCCI

81455 81256 NCCI

81455 81257 NCCI

81455 81260 NCCI

81455 81261 NCCI

81455 81262 NCCI

81455 81263 NCCI

81455 81264 NCCI

81455 81265 NCCI

81455 81266 NCCI

81455 81267 NCCI

Comprehensive ComponentCode Code Source

81455 81268 NCCI

81455 81270 NCCI

81455 81272 NCCI

81455 81273 NCCI

81455 81275 NCCI

81455 81276 NCCI

81455 81287 NCCI

81455 81288 NCCI

81455 81290 NCCI

81455 81291 NCCI

81455 81292 NCCI

81455 81293 NCCI

81455 81294 NCCI

81455 81295 NCCI

81455 81296 NCCI

81455 81297 NCCI

81455 81298 NCCI

81455 81299 NCCI

81455 81300 NCCI

81455 81301 NCCI

81455 81302 NCCI

81455 81303 NCCI

81455 81304 NCCI

81455 81310 NCCI

81455 81311 NCCI

81455 81313 NCCI

81455 81314 NCCI

81455 81315 NCCI

81455 81316 NCCI

81455 81317 NCCI

81455 81318 NCCI

81455 81319 NCCI

81455 81321 NCCI

81455 81322 NCCI

81455 81323 NCCI

81455 81324 NCCI

81455 81325 NCCI

81455 81326 NCCI

81455 81327 NCCI

81455 81330 NCCI

81455 81331 NCCI

81455 81332 NCCI

81455 81340 NCCI

81455 81341 NCCI

81455 81342 NCCI

81455 81350 NCCI

81455 81355 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 193 of 255

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Comprehensive ComponentCode Code Source

81455 81400 NCCI

81455 81401 NCCI

81455 81402 NCCI

81455 81403 NCCI

81455 81404 NCCI

81455 81405 NCCI

81455 81406 NCCI

81455 81407 NCCI

81455 81408 NCCI

81455 81445 NCCI

81455 81450 NCCI

81455 81493 NCCI

81455 81504 NCCI

81455 81507 NCCI

81455 81519 NCCI

81455 81525 NCCI

81455 81528 NCCI

81455 81540 NCCI

81455 81545 NCCI

81455 81595 NCCI

81455 84311 NCCI

81455 88271 NCCI

81455 88272 NCCI

81455 88273 NCCI

81455 88274 NCCI

81455 88275 NCCI

81455 88291 NCCI

81455 88364 NCCI

81455 88365 NCCI

81455 88366 NCCI

81455 88367 NCCI

81455 88368 NCCI

81455 88369 NCCI

81455 88373 NCCI

81455 88374 NCCI

81455 88377 NCCI

81455 G0452 NCCI

81460 80500 NCCI

81460 80502 NCCI

81460 81161 NCCI

81460 81162 NCCI

81460 81170 NCCI

81460 81200 NCCI

81460 81201 NCCI

81460 81202 NCCI

81460 81203 NCCI

81460 81205 NCCI

Comprehensive ComponentCode Code Source

81460 81206 NCCI

81460 81207 NCCI

81460 81208 NCCI

81460 81209 NCCI

81460 81210 NCCI

81460 81211 NCCI

81460 81212 NCCI

81460 81213 NCCI

81460 81214 NCCI

81460 81215 NCCI

81460 81216 NCCI

81460 81217 NCCI

81460 81218 NCCI

81460 81219 NCCI

81460 81220 NCCI

81460 81221 NCCI

81460 81222 NCCI

81460 81223 NCCI

81460 81224 NCCI

81460 81225 NCCI

81460 81226 NCCI

81460 81227 NCCI

81460 81235 NCCI

81460 81240 NCCI

81460 81241 NCCI

81460 81242 NCCI

81460 81243 NCCI

81460 81244 NCCI

81460 81245 NCCI

81460 81246 NCCI

81460 81250 NCCI

81460 81251 NCCI

81460 81252 NCCI

81460 81253 NCCI

81460 81254 NCCI

81460 81255 NCCI

81460 81256 NCCI

81460 81257 NCCI

81460 81260 NCCI

81460 81261 NCCI

81460 81262 NCCI

81460 81263 NCCI

81460 81264 NCCI

81460 81265 NCCI

81460 81266 NCCI

81460 81267 NCCI

81460 81268 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 194 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81460 81270 NCCI

81460 81272 NCCI

81460 81273 NCCI

81460 81275 NCCI

81460 81276 NCCI

81460 81287 NCCI

81460 81288 NCCI

81460 81290 NCCI

81460 81291 NCCI

81460 81292 NCCI

81460 81293 NCCI

81460 81294 NCCI

81460 81295 NCCI

81460 81296 NCCI

81460 81297 NCCI

81460 81298 NCCI

81460 81299 NCCI

81460 81300 NCCI

81460 81301 NCCI

81460 81302 NCCI

81460 81303 NCCI

81460 81304 NCCI

81460 81310 NCCI

81460 81311 NCCI

81460 81313 NCCI

81460 81314 NCCI

81460 81315 NCCI

81460 81316 NCCI

81460 81317 NCCI

81460 81318 NCCI

81460 81319 NCCI

81460 81321 NCCI

81460 81322 NCCI

81460 81323 NCCI

81460 81324 NCCI

81460 81325 NCCI

81460 81326 NCCI

81460 81327 NCCI

81460 81330 NCCI

81460 81331 NCCI

81460 81332 NCCI

81460 81340 NCCI

81460 81341 NCCI

81460 81342 NCCI

81460 81350 NCCI

81460 81355 NCCI

81460 81400 NCCI

Comprehensive ComponentCode Code Source

81460 81401 NCCI

81460 81402 NCCI

81460 81403 NCCI

81460 81404 NCCI

81460 81405 NCCI

81460 81406 NCCI

81460 81407 NCCI

81460 81408 NCCI

81460 81493 NCCI

81460 81504 NCCI

81460 81507 NCCI

81460 81519 NCCI

81460 81525 NCCI

81460 81528 NCCI

81460 81540 NCCI

81460 81545 NCCI

81460 81595 NCCI

81460 84311 NCCI

81460 88271 NCCI

81460 88272 NCCI

81460 88273 NCCI

81460 88274 NCCI

81460 88275 NCCI

81460 88291 NCCI

81460 88364 NCCI

81460 88365 NCCI

81460 88366 NCCI

81460 88367 NCCI

81460 88368 NCCI

81460 88369 NCCI

81460 88373 NCCI

81460 88374 NCCI

81460 88377 NCCI

81460 G0452 NCCI

81465 80500 NCCI

81465 80502 NCCI

81465 81161 NCCI

81465 81162 NCCI

81465 81170 NCCI

81465 81200 NCCI

81465 81201 NCCI

81465 81202 NCCI

81465 81203 NCCI

81465 81205 NCCI

81465 81206 NCCI

81465 81207 NCCI

81465 81208 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 195 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81465 81209 NCCI

81465 81210 NCCI

81465 81211 NCCI

81465 81212 NCCI

81465 81213 NCCI

81465 81214 NCCI

81465 81215 NCCI

81465 81216 NCCI

81465 81217 NCCI

81465 81218 NCCI

81465 81219 NCCI

81465 81220 NCCI

81465 81221 NCCI

81465 81222 NCCI

81465 81223 NCCI

81465 81224 NCCI

81465 81225 NCCI

81465 81226 NCCI

81465 81227 NCCI

81465 81235 NCCI

81465 81240 NCCI

81465 81241 NCCI

81465 81242 NCCI

81465 81243 NCCI

81465 81244 NCCI

81465 81245 NCCI

81465 81246 NCCI

81465 81250 NCCI

81465 81251 NCCI

81465 81252 NCCI

81465 81253 NCCI

81465 81254 NCCI

81465 81255 NCCI

81465 81256 NCCI

81465 81257 NCCI

81465 81260 NCCI

81465 81261 NCCI

81465 81262 NCCI

81465 81263 NCCI

81465 81264 NCCI

81465 81265 NCCI

81465 81266 NCCI

81465 81267 NCCI

81465 81268 NCCI

81465 81270 NCCI

81465 81272 NCCI

81465 81273 NCCI

Comprehensive ComponentCode Code Source

81465 81275 NCCI

81465 81276 NCCI

81465 81287 NCCI

81465 81288 NCCI

81465 81290 NCCI

81465 81291 NCCI

81465 81292 NCCI

81465 81293 NCCI

81465 81294 NCCI

81465 81295 NCCI

81465 81296 NCCI

81465 81297 NCCI

81465 81298 NCCI

81465 81299 NCCI

81465 81300 NCCI

81465 81301 NCCI

81465 81302 NCCI

81465 81303 NCCI

81465 81304 NCCI

81465 81310 NCCI

81465 81311 NCCI

81465 81313 NCCI

81465 81314 NCCI

81465 81315 NCCI

81465 81316 NCCI

81465 81317 NCCI

81465 81318 NCCI

81465 81319 NCCI

81465 81321 NCCI

81465 81322 NCCI

81465 81323 NCCI

81465 81324 NCCI

81465 81325 NCCI

81465 81326 NCCI

81465 81327 NCCI

81465 81330 NCCI

81465 81331 NCCI

81465 81332 NCCI

81465 81340 NCCI

81465 81341 NCCI

81465 81342 NCCI

81465 81350 NCCI

81465 81355 NCCI

81465 81400 NCCI

81465 81401 NCCI

81465 81402 NCCI

81465 81403 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 196 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81465 81404 NCCI

81465 81405 NCCI

81465 81406 NCCI

81465 81407 NCCI

81465 81408 NCCI

81465 81493 NCCI

81465 81504 NCCI

81465 81507 NCCI

81465 81519 NCCI

81465 81525 NCCI

81465 81528 NCCI

81465 81540 NCCI

81465 81545 NCCI

81465 81595 NCCI

81465 84311 NCCI

81465 88271 NCCI

81465 88272 NCCI

81465 88273 NCCI

81465 88274 NCCI

81465 88275 NCCI

81465 88291 NCCI

81465 88364 NCCI

81465 88365 NCCI

81465 88366 NCCI

81465 88367 NCCI

81465 88368 NCCI

81465 88369 NCCI

81465 88373 NCCI

81465 88374 NCCI

81465 88377 NCCI

81465 G0452 NCCI

81470 80500 NCCI

81470 80502 NCCI

81470 81161 NCCI

81470 81162 NCCI

81470 81170 NCCI

81470 81200 NCCI

81470 81201 NCCI

81470 81202 NCCI

81470 81203 NCCI

81470 81205 NCCI

81470 81206 NCCI

81470 81207 NCCI

81470 81208 NCCI

81470 81209 NCCI

81470 81210 NCCI

81470 81211 NCCI

Comprehensive ComponentCode Code Source

81470 81212 NCCI

81470 81213 NCCI

81470 81214 NCCI

81470 81215 NCCI

81470 81216 NCCI

81470 81217 NCCI

81470 81218 NCCI

81470 81219 NCCI

81470 81220 NCCI

81470 81221 NCCI

81470 81222 NCCI

81470 81223 NCCI

81470 81224 NCCI

81470 81225 NCCI

81470 81226 NCCI

81470 81227 NCCI

81470 81235 NCCI

81470 81240 NCCI

81470 81241 NCCI

81470 81242 NCCI

81470 81243 NCCI

81470 81244 NCCI

81470 81245 NCCI

81470 81246 NCCI

81470 81250 NCCI

81470 81251 NCCI

81470 81252 NCCI

81470 81253 NCCI

81470 81254 NCCI

81470 81255 NCCI

81470 81256 NCCI

81470 81257 NCCI

81470 81260 NCCI

81470 81261 NCCI

81470 81262 NCCI

81470 81263 NCCI

81470 81264 NCCI

81470 81265 NCCI

81470 81266 NCCI

81470 81267 NCCI

81470 81268 NCCI

81470 81270 NCCI

81470 81272 NCCI

81470 81273 NCCI

81470 81275 NCCI

81470 81276 NCCI

81470 81287 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 197 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81470 81288 NCCI

81470 81290 NCCI

81470 81291 NCCI

81470 81292 NCCI

81470 81293 NCCI

81470 81294 NCCI

81470 81295 NCCI

81470 81296 NCCI

81470 81297 NCCI

81470 81298 NCCI

81470 81299 NCCI

81470 81300 NCCI

81470 81301 NCCI

81470 81302 NCCI

81470 81303 NCCI

81470 81304 NCCI

81470 81310 NCCI

81470 81311 NCCI

81470 81313 NCCI

81470 81314 NCCI

81470 81315 NCCI

81470 81316 NCCI

81470 81317 NCCI

81470 81318 NCCI

81470 81319 NCCI

81470 81321 NCCI

81470 81322 NCCI

81470 81323 NCCI

81470 81324 NCCI

81470 81325 NCCI

81470 81326 NCCI

81470 81327 NCCI

81470 81330 NCCI

81470 81331 NCCI

81470 81332 NCCI

81470 81340 NCCI

81470 81341 NCCI

81470 81342 NCCI

81470 81350 NCCI

81470 81355 NCCI

81470 81400 NCCI

81470 81401 NCCI

81470 81402 NCCI

81470 81403 NCCI

81470 81404 NCCI

81470 81405 NCCI

81470 81406 NCCI

Comprehensive ComponentCode Code Source

81470 81407 NCCI

81470 81408 NCCI

81470 81493 NCCI

81470 81504 NCCI

81470 81507 NCCI

81470 81519 NCCI

81470 81525 NCCI

81470 81528 NCCI

81470 81540 NCCI

81470 81545 NCCI

81470 81595 NCCI

81470 84311 NCCI

81470 88271 NCCI

81470 88272 NCCI

81470 88273 NCCI

81470 88274 NCCI

81470 88275 NCCI

81470 88291 NCCI

81470 88364 NCCI

81470 88365 NCCI

81470 88366 NCCI

81470 88367 NCCI

81470 88368 NCCI

81470 88369 NCCI

81470 88373 NCCI

81470 88374 NCCI

81470 88377 NCCI

81470 G0452 NCCI

81471 80500 NCCI

81471 80502 NCCI

81471 81161 NCCI

81471 81162 NCCI

81471 81170 NCCI

81471 81200 NCCI

81471 81201 NCCI

81471 81202 NCCI

81471 81203 NCCI

81471 81205 NCCI

81471 81206 NCCI

81471 81207 NCCI

81471 81208 NCCI

81471 81209 NCCI

81471 81210 NCCI

81471 81211 NCCI

81471 81212 NCCI

81471 81213 NCCI

81471 81214 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 198 of 255

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Comprehensive ComponentCode Code Source

81471 81215 NCCI

81471 81216 NCCI

81471 81217 NCCI

81471 81218 NCCI

81471 81219 NCCI

81471 81220 NCCI

81471 81221 NCCI

81471 81222 NCCI

81471 81223 NCCI

81471 81224 NCCI

81471 81225 NCCI

81471 81226 NCCI

81471 81227 NCCI

81471 81235 NCCI

81471 81240 NCCI

81471 81241 NCCI

81471 81242 NCCI

81471 81243 NCCI

81471 81244 NCCI

81471 81245 NCCI

81471 81246 NCCI

81471 81250 NCCI

81471 81251 NCCI

81471 81252 NCCI

81471 81253 NCCI

81471 81254 NCCI

81471 81255 NCCI

81471 81256 NCCI

81471 81257 NCCI

81471 81260 NCCI

81471 81261 NCCI

81471 81262 NCCI

81471 81263 NCCI

81471 81264 NCCI

81471 81265 NCCI

81471 81266 NCCI

81471 81267 NCCI

81471 81268 NCCI

81471 81270 NCCI

81471 81272 NCCI

81471 81273 NCCI

81471 81275 NCCI

81471 81276 NCCI

81471 81287 NCCI

81471 81288 NCCI

81471 81290 NCCI

81471 81291 NCCI

Comprehensive ComponentCode Code Source

81471 81292 NCCI

81471 81293 NCCI

81471 81294 NCCI

81471 81295 NCCI

81471 81296 NCCI

81471 81297 NCCI

81471 81298 NCCI

81471 81299 NCCI

81471 81300 NCCI

81471 81301 NCCI

81471 81302 NCCI

81471 81303 NCCI

81471 81304 NCCI

81471 81310 NCCI

81471 81311 NCCI

81471 81313 NCCI

81471 81314 NCCI

81471 81315 NCCI

81471 81316 NCCI

81471 81317 NCCI

81471 81318 NCCI

81471 81319 NCCI

81471 81321 NCCI

81471 81322 NCCI

81471 81323 NCCI

81471 81324 NCCI

81471 81325 NCCI

81471 81326 NCCI

81471 81327 NCCI

81471 81330 NCCI

81471 81331 NCCI

81471 81332 NCCI

81471 81340 NCCI

81471 81341 NCCI

81471 81342 NCCI

81471 81350 NCCI

81471 81355 NCCI

81471 81400 NCCI

81471 81401 NCCI

81471 81402 NCCI

81471 81403 NCCI

81471 81404 NCCI

81471 81405 NCCI

81471 81406 NCCI

81471 81407 NCCI

81471 81408 NCCI

81471 81493 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 199 of 255

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Comprehensive ComponentCode Code Source

81471 81504 NCCI

81471 81507 NCCI

81471 81519 NCCI

81471 81525 NCCI

81471 81528 NCCI

81471 81540 NCCI

81471 81545 NCCI

81471 81595 NCCI

81471 84311 NCCI

81471 88271 NCCI

81471 88272 NCCI

81471 88273 NCCI

81471 88274 NCCI

81471 88275 NCCI

81471 88291 NCCI

81471 88364 NCCI

81471 88365 NCCI

81471 88366 NCCI

81471 88367 NCCI

81471 88368 NCCI

81471 88369 NCCI

81471 88373 NCCI

81471 88374 NCCI

81471 88377 NCCI

81471 G0452 NCCI

81490 80500 NCCI

81490 80502 NCCI

81490 86140 NCCI

81490 88291 NCCI

81490 G0452 NCCI

81493 80500 NCCI

81493 80502 NCCI

81493 81161 NCCI

81493 81162 NCCI

81493 81170 NCCI

81493 81200 NCCI

81493 81201 NCCI

81493 81202 NCCI

81493 81203 NCCI

81493 81205 NCCI

81493 81206 NCCI

81493 81207 NCCI

81493 81208 NCCI

81493 81209 NCCI

81493 81210 NCCI

81493 81211 NCCI

81493 81212 NCCI

Comprehensive ComponentCode Code Source

81493 81213 NCCI

81493 81214 NCCI

81493 81215 NCCI

81493 81216 NCCI

81493 81217 NCCI

81493 81218 NCCI

81493 81219 NCCI

81493 81220 NCCI

81493 81221 NCCI

81493 81222 NCCI

81493 81223 NCCI

81493 81224 NCCI

81493 81225 NCCI

81493 81226 NCCI

81493 81227 NCCI

81493 81228 NCCI

81493 81229 NCCI

81493 81235 NCCI

81493 81240 NCCI

81493 81241 NCCI

81493 81242 NCCI

81493 81243 NCCI

81493 81244 NCCI

81493 81245 NCCI

81493 81246 NCCI

81493 81250 NCCI

81493 81251 NCCI

81493 81252 NCCI

81493 81253 NCCI

81493 81254 NCCI

81493 81255 NCCI

81493 81256 NCCI

81493 81257 NCCI

81493 81260 NCCI

81493 81261 NCCI

81493 81262 NCCI

81493 81263 NCCI

81493 81264 NCCI

81493 81265 NCCI

81493 81266 NCCI

81493 81267 NCCI

81493 81268 NCCI

81493 81270 NCCI

81493 81272 NCCI

81493 81273 NCCI

81493 81275 NCCI

81493 81276 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 200 of 255

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Comprehensive ComponentCode Code Source

81493 81288 NCCI

81493 81290 NCCI

81493 81291 NCCI

81493 81292 NCCI

81493 81293 NCCI

81493 81294 NCCI

81493 81295 NCCI

81493 81296 NCCI

81493 81297 NCCI

81493 81298 NCCI

81493 81299 NCCI

81493 81300 NCCI

81493 81301 NCCI

81493 81302 NCCI

81493 81303 NCCI

81493 81304 NCCI

81493 81310 NCCI

81493 81311 NCCI

81493 81313 NCCI

81493 81314 NCCI

81493 81315 NCCI

81493 81316 NCCI

81493 81317 NCCI

81493 81318 NCCI

81493 81319 NCCI

81493 81321 NCCI

81493 81322 NCCI

81493 81323 NCCI

81493 81324 NCCI

81493 81325 NCCI

81493 81326 NCCI

81493 81327 NCCI

81493 81330 NCCI

81493 81331 NCCI

81493 81332 NCCI

81493 81340 NCCI

81493 81341 NCCI

81493 81342 NCCI

81493 81350 NCCI

81493 81355 NCCI

81493 81400 NCCI

81493 81401 NCCI

81493 81402 NCCI

81493 81403 NCCI

81493 81404 NCCI

81493 81405 NCCI

81493 81406 NCCI

Comprehensive ComponentCode Code Source

81493 81407 NCCI

81493 81408 NCCI

81493 84311 NCCI

81493 88271 NCCI

81493 88272 NCCI

81493 88273 NCCI

81493 88274 NCCI

81493 88275 NCCI

81493 88291 NCCI

81493 88364 NCCI

81493 88365 NCCI

81493 88366 NCCI

81493 88367 NCCI

81493 88368 NCCI

81493 88369 NCCI

81493 88373 NCCI

81493 88374 NCCI

81493 88377 NCCI

81493 G0452 NCCI

81500 80500 NCCI

81500 80502 NCCI

81500 86304 NCCI

81500 86305 NCCI

81500 88291 NCCI

81500 G0452 NCCI

81503 80500 NCCI

81503 80502 NCCI

81503 82172 NCCI

81503 82232 NCCI

81503 83695 NCCI

81503 84134 NCCI

81503 84466 NCCI

81503 86304 NCCI

81503 88291 NCCI

81503 G0452 NCCI

81504 80500 NCCI

81504 80502 NCCI

81504 81161 NCCI

81504 81162 NCCI

81504 81170 NCCI

81504 81200 NCCI

81504 81201 NCCI

81504 81202 NCCI

81504 81203 NCCI

81504 81205 NCCI

81504 81206 NCCI

81504 81207 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 201 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81504 81208 NCCI

81504 81209 NCCI

81504 81210 NCCI

81504 81211 NCCI

81504 81212 NCCI

81504 81213 NCCI

81504 81214 NCCI

81504 81215 NCCI

81504 81216 NCCI

81504 81217 NCCI

81504 81218 NCCI

81504 81219 NCCI

81504 81220 NCCI

81504 81221 NCCI

81504 81222 NCCI

81504 81223 NCCI

81504 81224 NCCI

81504 81225 NCCI

81504 81226 NCCI

81504 81227 NCCI

81504 81228 NCCI

81504 81229 NCCI

81504 81235 NCCI

81504 81240 NCCI

81504 81241 NCCI

81504 81242 NCCI

81504 81243 NCCI

81504 81244 NCCI

81504 81245 NCCI

81504 81246 NCCI

81504 81250 NCCI

81504 81251 NCCI

81504 81252 NCCI

81504 81253 NCCI

81504 81254 NCCI

81504 81255 NCCI

81504 81256 NCCI

81504 81257 NCCI

81504 81260 NCCI

81504 81261 NCCI

81504 81262 NCCI

81504 81263 NCCI

81504 81264 NCCI

81504 81265 NCCI

81504 81266 NCCI

81504 81267 NCCI

81504 81268 NCCI

Comprehensive ComponentCode Code Source

81504 81270 NCCI

81504 81272 NCCI

81504 81273 NCCI

81504 81275 NCCI

81504 81276 NCCI

81504 81288 NCCI

81504 81290 NCCI

81504 81291 NCCI

81504 81292 NCCI

81504 81293 NCCI

81504 81294 NCCI

81504 81295 NCCI

81504 81296 NCCI

81504 81297 NCCI

81504 81298 NCCI

81504 81299 NCCI

81504 81300 NCCI

81504 81301 NCCI

81504 81302 NCCI

81504 81303 NCCI

81504 81304 NCCI

81504 81310 NCCI

81504 81311 NCCI

81504 81313 NCCI

81504 81314 NCCI

81504 81315 NCCI

81504 81316 NCCI

81504 81317 NCCI

81504 81318 NCCI

81504 81319 NCCI

81504 81321 NCCI

81504 81322 NCCI

81504 81323 NCCI

81504 81324 NCCI

81504 81325 NCCI

81504 81326 NCCI

81504 81327 NCCI

81504 81330 NCCI

81504 81331 NCCI

81504 81332 NCCI

81504 81340 NCCI

81504 81341 NCCI

81504 81342 NCCI

81504 81350 NCCI

81504 81355 NCCI

81504 81400 NCCI

81504 81401 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 202 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81504 81402 NCCI

81504 81403 NCCI

81504 81404 NCCI

81504 81405 NCCI

81504 81406 NCCI

81504 81407 NCCI

81504 81408 NCCI

81504 84311 NCCI

81504 88271 NCCI

81504 88272 NCCI

81504 88273 NCCI

81504 88274 NCCI

81504 88275 NCCI

81504 88291 NCCI

81504 88364 NCCI

81504 88365 NCCI

81504 88366 NCCI

81504 88367 NCCI

81504 88368 NCCI

81504 88369 NCCI

81504 88373 NCCI

81504 88374 NCCI

81504 88377 NCCI

81504 G0452 NCCI

81506 80500 NCCI

81506 80502 NCCI

81506 82728 NCCI

81506 82947 NCCI

81506 83036 NCCI

81506 83525 NCCI

81506 86141 NCCI

81506 88291 NCCI

81506 G0452 NCCI

81507 80500 NCCI

81507 80502 NCCI

81507 81161 NCCI

81507 81162 NCCI

81507 81170 NCCI

81507 81200 NCCI

81507 81201 NCCI

81507 81202 NCCI

81507 81203 NCCI

81507 81205 NCCI

81507 81206 NCCI

81507 81207 NCCI

81507 81208 NCCI

81507 81209 NCCI

Comprehensive ComponentCode Code Source

81507 81210 NCCI

81507 81211 NCCI

81507 81212 NCCI

81507 81213 NCCI

81507 81214 NCCI

81507 81215 NCCI

81507 81216 NCCI

81507 81217 NCCI

81507 81218 NCCI

81507 81219 NCCI

81507 81220 NCCI

81507 81221 NCCI

81507 81222 NCCI

81507 81223 NCCI

81507 81224 NCCI

81507 81225 NCCI

81507 81226 NCCI

81507 81227 NCCI

81507 81228 NCCI

81507 81229 NCCI

81507 81235 NCCI

81507 81240 NCCI

81507 81241 NCCI

81507 81242 NCCI

81507 81243 NCCI

81507 81244 NCCI

81507 81245 NCCI

81507 81246 NCCI

81507 81250 NCCI

81507 81251 NCCI

81507 81252 NCCI

81507 81253 NCCI

81507 81254 NCCI

81507 81255 NCCI

81507 81256 NCCI

81507 81257 NCCI

81507 81260 NCCI

81507 81261 NCCI

81507 81262 NCCI

81507 81263 NCCI

81507 81264 NCCI

81507 81265 NCCI

81507 81266 NCCI

81507 81267 NCCI

81507 81268 NCCI

81507 81270 NCCI

81507 81272 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 203 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81507 81273 NCCI

81507 81275 NCCI

81507 81276 NCCI

81507 81288 NCCI

81507 81290 NCCI

81507 81291 NCCI

81507 81292 NCCI

81507 81293 NCCI

81507 81294 NCCI

81507 81295 NCCI

81507 81296 NCCI

81507 81297 NCCI

81507 81298 NCCI

81507 81299 NCCI

81507 81300 NCCI

81507 81301 NCCI

81507 81302 NCCI

81507 81303 NCCI

81507 81304 NCCI

81507 81310 NCCI

81507 81311 NCCI

81507 81313 NCCI

81507 81314 NCCI

81507 81315 NCCI

81507 81316 NCCI

81507 81317 NCCI

81507 81318 NCCI

81507 81319 NCCI

81507 81321 NCCI

81507 81322 NCCI

81507 81323 NCCI

81507 81324 NCCI

81507 81325 NCCI

81507 81326 NCCI

81507 81327 NCCI

81507 81330 NCCI

81507 81331 NCCI

81507 81332 NCCI

81507 81340 NCCI

81507 81341 NCCI

81507 81342 NCCI

81507 81350 NCCI

81507 81355 NCCI

81507 81400 NCCI

81507 81401 NCCI

81507 81402 NCCI

81507 81403 NCCI

Comprehensive ComponentCode Code Source

81507 81404 NCCI

81507 81405 NCCI

81507 81406 NCCI

81507 81407 NCCI

81507 81408 NCCI

81507 84311 NCCI

81507 88271 NCCI

81507 88272 NCCI

81507 88273 NCCI

81507 88274 NCCI

81507 88275 NCCI

81507 88291 NCCI

81507 88364 NCCI

81507 88365 NCCI

81507 88366 NCCI

81507 88367 NCCI

81507 88368 NCCI

81507 88369 NCCI

81507 88373 NCCI

81507 88374 NCCI

81507 88377 NCCI

81507 G0452 NCCI

81508 80500 NCCI

81508 80502 NCCI

81508 84163 NCCI

81508 84702 NCCI

81508 88291 NCCI

81508 G0452 NCCI

81509 80500 NCCI

81509 80502 NCCI

81509 84163 NCCI

81509 84702 NCCI

81509 86336 NCCI

81509 88291 NCCI

81509 G0452 NCCI

81510 80500 NCCI

81510 80502 NCCI

81510 82105 NCCI

81510 82677 NCCI

81510 84702 NCCI

81510 88291 NCCI

81510 G0452 NCCI

81511 80500 NCCI

81511 80502 NCCI

81511 82105 NCCI

81511 82677 NCCI

81511 84702 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 204 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81511 86336 NCCI

81511 88291 NCCI

81511 G0452 NCCI

81512 80500 NCCI

81512 80502 NCCI

81512 82105 NCCI

81512 82677 NCCI

81512 84702 NCCI

81512 86336 NCCI

81512 88291 NCCI

81512 G0452 NCCI

81519 80500 NCCI

81519 80502 NCCI

81519 81161 NCCI

81519 81162 NCCI

81519 81170 NCCI

81519 81200 NCCI

81519 81201 NCCI

81519 81202 NCCI

81519 81203 NCCI

81519 81205 NCCI

81519 81206 NCCI

81519 81207 NCCI

81519 81208 NCCI

81519 81209 NCCI

81519 81210 NCCI

81519 81211 NCCI

81519 81212 NCCI

81519 81213 NCCI

81519 81214 NCCI

81519 81215 NCCI

81519 81216 NCCI

81519 81217 NCCI

81519 81218 NCCI

81519 81219 NCCI

81519 81220 NCCI

81519 81221 NCCI

81519 81222 NCCI

81519 81223 NCCI

81519 81224 NCCI

81519 81225 NCCI

81519 81226 NCCI

81519 81227 NCCI

81519 81228 NCCI

81519 81229 NCCI

81519 81235 NCCI

81519 81240 NCCI

Comprehensive ComponentCode Code Source

81519 81241 NCCI

81519 81242 NCCI

81519 81243 NCCI

81519 81244 NCCI

81519 81245 NCCI

81519 81246 NCCI

81519 81250 NCCI

81519 81251 NCCI

81519 81252 NCCI

81519 81253 NCCI

81519 81254 NCCI

81519 81255 NCCI

81519 81256 NCCI

81519 81257 NCCI

81519 81260 NCCI

81519 81261 NCCI

81519 81262 NCCI

81519 81263 NCCI

81519 81264 NCCI

81519 81265 NCCI

81519 81266 NCCI

81519 81267 NCCI

81519 81268 NCCI

81519 81270 NCCI

81519 81272 NCCI

81519 81273 NCCI

81519 81275 NCCI

81519 81276 NCCI

81519 81288 NCCI

81519 81290 NCCI

81519 81291 NCCI

81519 81292 NCCI

81519 81293 NCCI

81519 81294 NCCI

81519 81295 NCCI

81519 81296 NCCI

81519 81297 NCCI

81519 81298 NCCI

81519 81299 NCCI

81519 81300 NCCI

81519 81301 NCCI

81519 81302 NCCI

81519 81303 NCCI

81519 81304 NCCI

81519 81310 NCCI

81519 81311 NCCI

81519 81313 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 205 of 255

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Comprehensive ComponentCode Code Source

81519 81314 NCCI

81519 81315 NCCI

81519 81316 NCCI

81519 81317 NCCI

81519 81318 NCCI

81519 81319 NCCI

81519 81321 NCCI

81519 81322 NCCI

81519 81323 NCCI

81519 81324 NCCI

81519 81325 NCCI

81519 81326 NCCI

81519 81327 NCCI

81519 81330 NCCI

81519 81331 NCCI

81519 81332 NCCI

81519 81340 NCCI

81519 81341 NCCI

81519 81342 NCCI

81519 81350 NCCI

81519 81355 NCCI

81519 81400 NCCI

81519 81401 NCCI

81519 81402 NCCI

81519 81403 NCCI

81519 81404 NCCI

81519 81405 NCCI

81519 81406 NCCI

81519 81407 NCCI

81519 81408 NCCI

81519 84311 NCCI

81519 88271 NCCI

81519 88272 NCCI

81519 88273 NCCI

81519 88274 NCCI

81519 88275 NCCI

81519 88291 NCCI

81519 88364 NCCI

81519 88365 NCCI

81519 88366 NCCI

81519 88367 NCCI

81519 88368 NCCI

81519 88369 NCCI

81519 88373 NCCI

81519 88374 NCCI

81519 88377 NCCI

81519 G0452 NCCI

Comprehensive ComponentCode Code Source

81525 80500 NCCI

81525 80502 NCCI

81525 81161 NCCI

81525 81162 NCCI

81525 81170 NCCI

81525 81200 NCCI

81525 81201 NCCI

81525 81202 NCCI

81525 81203 NCCI

81525 81205 NCCI

81525 81206 NCCI

81525 81207 NCCI

81525 81208 NCCI

81525 81209 NCCI

81525 81210 NCCI

81525 81211 NCCI

81525 81212 NCCI

81525 81213 NCCI

81525 81214 NCCI

81525 81215 NCCI

81525 81216 NCCI

81525 81217 NCCI

81525 81218 NCCI

81525 81219 NCCI

81525 81220 NCCI

81525 81221 NCCI

81525 81222 NCCI

81525 81223 NCCI

81525 81224 NCCI

81525 81225 NCCI

81525 81226 NCCI

81525 81227 NCCI

81525 81228 NCCI

81525 81229 NCCI

81525 81235 NCCI

81525 81240 NCCI

81525 81241 NCCI

81525 81242 NCCI

81525 81243 NCCI

81525 81244 NCCI

81525 81245 NCCI

81525 81246 NCCI

81525 81250 NCCI

81525 81251 NCCI

81525 81252 NCCI

81525 81253 NCCI

81525 81254 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 206 of 255

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Comprehensive ComponentCode Code Source

81525 81255 NCCI

81525 81256 NCCI

81525 81257 NCCI

81525 81260 NCCI

81525 81261 NCCI

81525 81262 NCCI

81525 81263 NCCI

81525 81264 NCCI

81525 81265 NCCI

81525 81266 NCCI

81525 81267 NCCI

81525 81268 NCCI

81525 81270 NCCI

81525 81272 NCCI

81525 81273 NCCI

81525 81275 NCCI

81525 81276 NCCI

81525 81288 NCCI

81525 81290 NCCI

81525 81291 NCCI

81525 81292 NCCI

81525 81293 NCCI

81525 81294 NCCI

81525 81295 NCCI

81525 81296 NCCI

81525 81297 NCCI

81525 81298 NCCI

81525 81299 NCCI

81525 81300 NCCI

81525 81301 NCCI

81525 81302 NCCI

81525 81303 NCCI

81525 81304 NCCI

81525 81310 NCCI

81525 81311 NCCI

81525 81313 NCCI

81525 81314 NCCI

81525 81315 NCCI

81525 81316 NCCI

81525 81317 NCCI

81525 81318 NCCI

81525 81319 NCCI

81525 81321 NCCI

81525 81322 NCCI

81525 81323 NCCI

81525 81324 NCCI

81525 81325 NCCI

Comprehensive ComponentCode Code Source

81525 81326 NCCI

81525 81327 NCCI

81525 81330 NCCI

81525 81331 NCCI

81525 81332 NCCI

81525 81340 NCCI

81525 81341 NCCI

81525 81342 NCCI

81525 81350 NCCI

81525 81355 NCCI

81525 81400 NCCI

81525 81401 NCCI

81525 81402 NCCI

81525 81403 NCCI

81525 81404 NCCI

81525 81405 NCCI

81525 81406 NCCI

81525 81407 NCCI

81525 81408 NCCI

81525 84311 NCCI

81525 88271 NCCI

81525 88272 NCCI

81525 88273 NCCI

81525 88274 NCCI

81525 88275 NCCI

81525 88291 NCCI

81525 88364 NCCI

81525 88365 NCCI

81525 88366 NCCI

81525 88367 NCCI

81525 88368 NCCI

81525 88369 NCCI

81525 88373 NCCI

81525 88374 NCCI

81525 88377 NCCI

81525 G0452 NCCI

81528 80500 NCCI

81528 80502 NCCI

81528 81161 NCCI

81528 81162 NCCI

81528 81170 NCCI

81528 81200 NCCI

81528 81201 NCCI

81528 81202 NCCI

81528 81203 NCCI

81528 81205 NCCI

81528 81206 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 207 of 255

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Comprehensive ComponentCode Code Source

81528 81207 NCCI

81528 81208 NCCI

81528 81209 NCCI

81528 81210 NCCI

81528 81211 NCCI

81528 81212 NCCI

81528 81213 NCCI

81528 81214 NCCI

81528 81215 NCCI

81528 81216 NCCI

81528 81217 NCCI

81528 81218 NCCI

81528 81219 NCCI

81528 81220 NCCI

81528 81221 NCCI

81528 81222 NCCI

81528 81223 NCCI

81528 81224 NCCI

81528 81225 NCCI

81528 81226 NCCI

81528 81227 NCCI

81528 81228 NCCI

81528 81229 NCCI

81528 81235 NCCI

81528 81240 NCCI

81528 81241 NCCI

81528 81242 NCCI

81528 81243 NCCI

81528 81244 NCCI

81528 81245 NCCI

81528 81246 NCCI

81528 81250 NCCI

81528 81251 NCCI

81528 81252 NCCI

81528 81253 NCCI

81528 81254 NCCI

81528 81255 NCCI

81528 81256 NCCI

81528 81257 NCCI

81528 81260 NCCI

81528 81261 NCCI

81528 81262 NCCI

81528 81263 NCCI

81528 81264 NCCI

81528 81265 NCCI

81528 81266 NCCI

81528 81267 NCCI

Comprehensive ComponentCode Code Source

81528 81268 NCCI

81528 81270 NCCI

81528 81272 NCCI

81528 81273 NCCI

81528 81275 NCCI

81528 81276 NCCI

81528 81288 NCCI

81528 81290 NCCI

81528 81291 NCCI

81528 81292 NCCI

81528 81293 NCCI

81528 81294 NCCI

81528 81295 NCCI

81528 81296 NCCI

81528 81297 NCCI

81528 81298 NCCI

81528 81299 NCCI

81528 81300 NCCI

81528 81301 NCCI

81528 81302 NCCI

81528 81303 NCCI

81528 81304 NCCI

81528 81310 NCCI

81528 81311 NCCI

81528 81313 NCCI

81528 81314 NCCI

81528 81315 NCCI

81528 81316 NCCI

81528 81317 NCCI

81528 81318 NCCI

81528 81319 NCCI

81528 81321 NCCI

81528 81322 NCCI

81528 81323 NCCI

81528 81324 NCCI

81528 81325 NCCI

81528 81326 NCCI

81528 81327 NCCI

81528 81330 NCCI

81528 81331 NCCI

81528 81332 NCCI

81528 81340 NCCI

81528 81341 NCCI

81528 81342 NCCI

81528 81350 NCCI

81528 81355 NCCI

81528 81400 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 208 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81528 81401 NCCI

81528 81402 NCCI

81528 81403 NCCI

81528 81404 NCCI

81528 81405 NCCI

81528 81406 NCCI

81528 81407 NCCI

81528 81408 NCCI

81528 82270 NCCI

81528 82272 NCCI

81528 82274 NCCI

81528 84311 NCCI

81528 88271 NCCI

81528 88272 NCCI

81528 88273 NCCI

81528 88274 NCCI

81528 88275 NCCI

81528 88291 NCCI

81528 88364 NCCI

81528 88365 NCCI

81528 88366 NCCI

81528 88367 NCCI

81528 88368 NCCI

81528 88369 NCCI

81528 88373 NCCI

81528 88374 NCCI

81528 88377 NCCI

81528 G0452 NCCI

81535 80500 NCCI

81535 80502 NCCI

81535 81228 NCCI

81535 81229 NCCI

81535 88230 NCCI

81535 88233 NCCI

81535 88235 NCCI

81535 88237 NCCI

81535 88239 NCCI

81535 88271 NCCI

81535 88291 NCCI

81535 88313 NCCI

81535 G0452 NCCI

81536 80500 NCCI

81536 80502 NCCI

81536 81228 NCCI

81536 81229 NCCI

81536 88230 NCCI

81536 88233 NCCI

Comprehensive ComponentCode Code Source

81536 88235 NCCI

81536 88237 NCCI

81536 88239 NCCI

81536 88271 NCCI

81536 88291 NCCI

81536 88313 NCCI

81536 G0452 NCCI

81538 80500 NCCI

81538 80502 NCCI

81538 83789 NCCI

81538 88291 NCCI

81538 G0452 NCCI

81539 80500 NCCI

81539 80502 NCCI

81539 84152 NCCI

81539 84153 NCCI

81539 84154 NCCI

81539 88291 NCCI

81539 96523 NCCI

81539 G0452 NCCI

81540 80500 NCCI

81540 80502 NCCI

81540 81161 NCCI

81540 81162 NCCI

81540 81170 NCCI

81540 81200 NCCI

81540 81201 NCCI

81540 81202 NCCI

81540 81203 NCCI

81540 81205 NCCI

81540 81206 NCCI

81540 81207 NCCI

81540 81208 NCCI

81540 81209 NCCI

81540 81210 NCCI

81540 81211 NCCI

81540 81212 NCCI

81540 81213 NCCI

81540 81214 NCCI

81540 81215 NCCI

81540 81216 NCCI

81540 81217 NCCI

81540 81218 NCCI

81540 81219 NCCI

81540 81220 NCCI

81540 81221 NCCI

81540 81222 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 209 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81540 81223 NCCI

81540 81224 NCCI

81540 81225 NCCI

81540 81226 NCCI

81540 81227 NCCI

81540 81228 NCCI

81540 81229 NCCI

81540 81235 NCCI

81540 81240 NCCI

81540 81241 NCCI

81540 81242 NCCI

81540 81243 NCCI

81540 81244 NCCI

81540 81245 NCCI

81540 81246 NCCI

81540 81250 NCCI

81540 81251 NCCI

81540 81252 NCCI

81540 81253 NCCI

81540 81254 NCCI

81540 81255 NCCI

81540 81256 NCCI

81540 81257 NCCI

81540 81260 NCCI

81540 81261 NCCI

81540 81262 NCCI

81540 81263 NCCI

81540 81264 NCCI

81540 81265 NCCI

81540 81266 NCCI

81540 81267 NCCI

81540 81268 NCCI

81540 81270 NCCI

81540 81272 NCCI

81540 81273 NCCI

81540 81275 NCCI

81540 81276 NCCI

81540 81288 NCCI

81540 81290 NCCI

81540 81291 NCCI

81540 81292 NCCI

81540 81293 NCCI

81540 81294 NCCI

81540 81295 NCCI

81540 81296 NCCI

81540 81297 NCCI

81540 81298 NCCI

Comprehensive ComponentCode Code Source

81540 81299 NCCI

81540 81300 NCCI

81540 81301 NCCI

81540 81302 NCCI

81540 81303 NCCI

81540 81304 NCCI

81540 81310 NCCI

81540 81311 NCCI

81540 81313 NCCI

81540 81314 NCCI

81540 81315 NCCI

81540 81316 NCCI

81540 81317 NCCI

81540 81318 NCCI

81540 81319 NCCI

81540 81321 NCCI

81540 81322 NCCI

81540 81323 NCCI

81540 81324 NCCI

81540 81325 NCCI

81540 81326 NCCI

81540 81327 NCCI

81540 81330 NCCI

81540 81331 NCCI

81540 81332 NCCI

81540 81340 NCCI

81540 81341 NCCI

81540 81342 NCCI

81540 81350 NCCI

81540 81355 NCCI

81540 81400 NCCI

81540 81401 NCCI

81540 81402 NCCI

81540 81403 NCCI

81540 81404 NCCI

81540 81405 NCCI

81540 81406 NCCI

81540 81407 NCCI

81540 81408 NCCI

81540 84311 NCCI

81540 88271 NCCI

81540 88272 NCCI

81540 88273 NCCI

81540 88274 NCCI

81540 88275 NCCI

81540 88291 NCCI

81540 88364 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 210 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81540 88365 NCCI

81540 88366 NCCI

81540 88367 NCCI

81540 88368 NCCI

81540 88369 NCCI

81540 88373 NCCI

81540 88374 NCCI

81540 88377 NCCI

81540 G0452 NCCI

81545 80500 NCCI

81545 80502 NCCI

81545 81161 NCCI

81545 81162 NCCI

81545 81170 NCCI

81545 81200 NCCI

81545 81201 NCCI

81545 81202 NCCI

81545 81203 NCCI

81545 81205 NCCI

81545 81206 NCCI

81545 81207 NCCI

81545 81208 NCCI

81545 81209 NCCI

81545 81210 NCCI

81545 81211 NCCI

81545 81212 NCCI

81545 81213 NCCI

81545 81214 NCCI

81545 81215 NCCI

81545 81216 NCCI

81545 81217 NCCI

81545 81218 NCCI

81545 81219 NCCI

81545 81220 NCCI

81545 81221 NCCI

81545 81222 NCCI

81545 81223 NCCI

81545 81224 NCCI

81545 81225 NCCI

81545 81226 NCCI

81545 81227 NCCI

81545 81228 NCCI

81545 81229 NCCI

81545 81235 NCCI

81545 81240 NCCI

81545 81241 NCCI

81545 81242 NCCI

Comprehensive ComponentCode Code Source

81545 81243 NCCI

81545 81244 NCCI

81545 81245 NCCI

81545 81246 NCCI

81545 81250 NCCI

81545 81251 NCCI

81545 81252 NCCI

81545 81253 NCCI

81545 81254 NCCI

81545 81255 NCCI

81545 81256 NCCI

81545 81257 NCCI

81545 81260 NCCI

81545 81261 NCCI

81545 81262 NCCI

81545 81263 NCCI

81545 81264 NCCI

81545 81265 NCCI

81545 81266 NCCI

81545 81267 NCCI

81545 81268 NCCI

81545 81270 NCCI

81545 81272 NCCI

81545 81273 NCCI

81545 81275 NCCI

81545 81276 NCCI

81545 81288 NCCI

81545 81290 NCCI

81545 81291 NCCI

81545 81292 NCCI

81545 81293 NCCI

81545 81294 NCCI

81545 81295 NCCI

81545 81296 NCCI

81545 81297 NCCI

81545 81298 NCCI

81545 81299 NCCI

81545 81300 NCCI

81545 81301 NCCI

81545 81302 NCCI

81545 81303 NCCI

81545 81304 NCCI

81545 81310 NCCI

81545 81311 NCCI

81545 81313 NCCI

81545 81314 NCCI

81545 81315 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 211 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81545 81316 NCCI

81545 81317 NCCI

81545 81318 NCCI

81545 81319 NCCI

81545 81321 NCCI

81545 81322 NCCI

81545 81323 NCCI

81545 81324 NCCI

81545 81325 NCCI

81545 81326 NCCI

81545 81327 NCCI

81545 81330 NCCI

81545 81331 NCCI

81545 81332 NCCI

81545 81340 NCCI

81545 81341 NCCI

81545 81342 NCCI

81545 81350 NCCI

81545 81355 NCCI

81545 81400 NCCI

81545 81401 NCCI

81545 81402 NCCI

81545 81403 NCCI

81545 81404 NCCI

81545 81405 NCCI

81545 81406 NCCI

81545 81407 NCCI

81545 81408 NCCI

81545 84311 NCCI

81545 88271 NCCI

81545 88272 NCCI

81545 88273 NCCI

81545 88274 NCCI

81545 88275 NCCI

81545 88291 NCCI

81545 88364 NCCI

81545 88365 NCCI

81545 88366 NCCI

81545 88367 NCCI

81545 88368 NCCI

81545 88369 NCCI

81545 88373 NCCI

81545 88374 NCCI

81545 88377 NCCI

81545 G0452 NCCI

81595 80500 NCCI

81595 80502 NCCI

Comprehensive ComponentCode Code Source

81595 81161 NCCI

81595 81162 NCCI

81595 81170 NCCI

81595 81200 NCCI

81595 81201 NCCI

81595 81202 NCCI

81595 81203 NCCI

81595 81205 NCCI

81595 81206 NCCI

81595 81207 NCCI

81595 81208 NCCI

81595 81209 NCCI

81595 81210 NCCI

81595 81211 NCCI

81595 81212 NCCI

81595 81213 NCCI

81595 81214 NCCI

81595 81215 NCCI

81595 81216 NCCI

81595 81217 NCCI

81595 81218 NCCI

81595 81219 NCCI

81595 81220 NCCI

81595 81221 NCCI

81595 81222 NCCI

81595 81223 NCCI

81595 81224 NCCI

81595 81225 NCCI

81595 81226 NCCI

81595 81227 NCCI

81595 81228 NCCI

81595 81229 NCCI

81595 81235 NCCI

81595 81240 NCCI

81595 81241 NCCI

81595 81242 NCCI

81595 81243 NCCI

81595 81244 NCCI

81595 81245 NCCI

81595 81246 NCCI

81595 81250 NCCI

81595 81251 NCCI

81595 81252 NCCI

81595 81253 NCCI

81595 81254 NCCI

81595 81255 NCCI

81595 81256 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 212 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

81595 81257 NCCI

81595 81260 NCCI

81595 81261 NCCI

81595 81262 NCCI

81595 81263 NCCI

81595 81264 NCCI

81595 81265 NCCI

81595 81266 NCCI

81595 81267 NCCI

81595 81268 NCCI

81595 81270 NCCI

81595 81272 NCCI

81595 81273 NCCI

81595 81275 NCCI

81595 81276 NCCI

81595 81288 NCCI

81595 81290 NCCI

81595 81291 NCCI

81595 81292 NCCI

81595 81293 NCCI

81595 81294 NCCI

81595 81295 NCCI

81595 81296 NCCI

81595 81297 NCCI

81595 81298 NCCI

81595 81299 NCCI

81595 81300 NCCI

81595 81301 NCCI

81595 81302 NCCI

81595 81303 NCCI

81595 81304 NCCI

81595 81310 NCCI

81595 81311 NCCI

81595 81313 NCCI

81595 81314 NCCI

81595 81315 NCCI

81595 81316 NCCI

81595 81317 NCCI

81595 81318 NCCI

81595 81319 NCCI

81595 81321 NCCI

81595 81322 NCCI

81595 81323 NCCI

81595 81324 NCCI

81595 81325 NCCI

81595 81326 NCCI

81595 81327 NCCI

Comprehensive ComponentCode Code Source

81595 81330 NCCI

81595 81331 NCCI

81595 81332 NCCI

81595 81340 NCCI

81595 81341 NCCI

81595 81342 NCCI

81595 81350 NCCI

81595 81355 NCCI

81595 81400 NCCI

81595 81401 NCCI

81595 81402 NCCI

81595 81403 NCCI

81595 81404 NCCI

81595 81405 NCCI

81595 81406 NCCI

81595 81407 NCCI

81595 81408 NCCI

81595 84311 NCCI

81595 88271 NCCI

81595 88272 NCCI

81595 88273 NCCI

81595 88274 NCCI

81595 88275 NCCI

81595 88291 NCCI

81595 88364 NCCI

81595 88365 NCCI

81595 88366 NCCI

81595 88367 NCCI

81595 88368 NCCI

81595 88369 NCCI

81595 88373 NCCI

81595 88374 NCCI

81595 88377 NCCI

81595 G0452 NCCI

82003 82003 BCBST

82010 82010 BCBST

82017 82016 NCCI

82024 80500 NCCI

82024 80502 NCCI

82024 82024 BCBST

82030 82030 BCBST

82043 82044 NCCI

82088 80500 NCCI

82088 80502 NCCI

82105 80500 NCCI

82105 80502 NCCI

82106 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 213 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

82106 80502 NCCI

82107 82105 NCCI

82127 82127 BCBST

82128 82127 NCCI

82128 82128 BCBST

82131 82136 NCCI

82131 82139 NCCI

82136 82136 BCBST

82136 82139 NCCI

82136 83090 NCCI

82139 82139 BCBST

82139 83090 NCCI

82140 82140 BCBST

82150 82150 BCBST

82180 84591 NCCI

82205 82205 BCBST

82247 82247 BCBST

82248 82248 BCBST

82270 82272 NCCI

82274 82270 NCCI

82274 82272 NCCI

82274 83026 NCCI

82306 84591 NCCI

82308 80500 NCCI

82308 80502 NCCI

82310 82310 BCBST

82310 82331 NCCI

82330 82330 BCBST

82331 82330 NCCI

82355 80500 NCCI

82355 80502 NCCI

82355 82355 BCBST

82360 80500 NCCI

82360 80502 NCCI

82360 82360 BCBST

82365 80500 NCCI

82365 80502 NCCI

82365 82365 BCBST

82370 80500 NCCI

82370 80502 NCCI

82370 82370 BCBST

82373 82373 BCBST

82374 82374 BCBST

82375 82375 BCBST

82375 88740 NCCI

82376 82376 BCBST

82376 88740 NCCI

Comprehensive ComponentCode Code Source

82384 80500 NCCI

82384 80502 NCCI

82415 82415 BCBST

82435 82435 BCBST

82438 82438 BCBST

82441 84600 NCCI

82465 80500 NCCI

82465 80502 NCCI

82465 83721 NCCI

82480 82480 BCBST

82482 82482 BCBST

82486 82486 BCBST

82487 82487 BCBST

82488 82488 BCBST

82489 82489 BCBST

82491 82491 BCBST

82492 82492 BCBST

82530 80500 NCCI

82530 80502 NCCI

82530 82530 BCBST

82533 80500 NCCI

82533 80502 NCCI

82533 82533 BCBST

82540 82540 BCBST

82541 82541 BCBST

82542 82542 BCBST

82543 82543 BCBST

82544 82544 BCBST

82550 80500 NCCI

82550 80502 NCCI

82550 82550 BCBST

82552 80500 NCCI

82552 80502 NCCI

82552 82552 BCBST

82552 82553 NCCI

82553 80500 NCCI

82553 80502 NCCI

82553 82553 BCBST

82554 80500 NCCI

82554 80502 NCCI

82554 82554 BCBST

82565 82565 BCBST

82570 82570 BCBST

82575 81050 NCCI

82575 82565 NCCI

82575 82570 NCCI

82607 82607 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 214 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

82607 84591 NCCI

82608 82608 BCBST

82634 80500 NCCI

82634 80502 NCCI

82634 82634 BCBST

82638 82638 BCBST

82652 84591 NCCI

82657 82657 BCBST

82658 82658 BCBST

82664 82664 BCBST

82666 82666 BCBST

82670 80500 NCCI

82670 80502 NCCI

82677 82677 BCBST

82693 82693 BCBST

82742 82742 BCBST

82784 80500 NCCI

82784 80502 NCCI

82785 80500 NCCI

82785 80502 NCCI

82787 80500 NCCI

82787 80502 NCCI

82800 80500 NCCI

82800 80502 NCCI

82800 82800 BCBST

82803 80500 NCCI

82803 80502 NCCI

82803 82800 NCCI

82803 82803 BCBST

82803 94760 NCCI

82803 94761 NCCI

82803 94762 NCCI

82805 80500 NCCI

82805 80502 NCCI

82805 82803 NCCI

82805 82805 BCBST

82805 82810 NCCI

82805 94760 NCCI

82805 94761 NCCI

82810 80500 NCCI

82810 80502 NCCI

82810 82803 NCCI

82810 82810 BCBST

82810 94760 NCCI

82810 94761 NCCI

82810 94762 NCCI

82820 80500 NCCI

Comprehensive ComponentCode Code Source

82820 80502 NCCI

82930 83986 NCCI

82945 82945 BCBST

82945 82947 NCCI

82945 82948 NCCI

82947 80500 NCCI

82947 80502 NCCI

82947 82947 BCBST

82947 82948 NCCI

82947 82951 NCCI

82948 82948 BCBST

82948 82950 NCCI

82948 82952 NCCI

82950 82951 NCCI

82951 80500 NCCI

82951 80502 NCCI

82951 82948 NCCI

82952 80500 NCCI

82952 80502 NCCI

82952 82947 NCCI

82962 82947 NCCI

82962 82948 NCCI

82962 82950 NCCI

82962 82951 NCCI

82962 82952 NCCI

82962 82962 BCBST

82985 83036 NCCI

82985 83037 NCCI

83001 80500 NCCI

83001 80502 NCCI

83002 80500 NCCI

83002 80502 NCCI

83003 80500 NCCI

83003 80502 NCCI

83003 83003 BCBST

83009 83519 NCCI

83009 83520 NCCI

83009 83789 NCCI

83009 87339 NCCI

83013 83519 NCCI

83013 83520 NCCI

83013 83789 NCCI

83014 78267 NCCI

83014 83520 NCCI

83014 83789 NCCI

83018 83018 BCBST

83020 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 215 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

83020 80502 NCCI

83021 80500 NCCI

83021 80502 NCCI

83030 80500 NCCI

83030 80502 NCCI

83030 83033 NCCI

83033 80500 NCCI

83033 80502 NCCI

83037 83036 NCCI

83050 83050 BCBST

83050 88741 NCCI

83051 83051 BCBST

83060 83060 BCBST

83068 80500 NCCI

83068 80502 NCCI

83088 83088 BCBST

83090 82127 NCCI

83090 82128 NCCI

83090 82131 NCCI

83498 80500 NCCI

83498 80502 NCCI

83516 83516 BCBST

83516 83518 NCCI

83518 83518 BCBST

83519 78267 NCCI

83519 83516 NCCI

83519 83519 BCBST

83520 78267 NCCI

83520 83519 NCCI

83520 83520 BCBST

83525 80500 NCCI

83525 80502 NCCI

83525 83525 BCBST

83527 83527 BCBST

83605 83605 BCBST

83615 83615 BCBST

83625 80500 NCCI

83625 80502 NCCI

83625 83625 BCBST

83631 83630 NCCI

83661 80500 NCCI

83661 80502 NCCI

83662 80500 NCCI

83662 80502 NCCI

83663 80500 NCCI

83663 80502 NCCI

83664 80500 NCCI

Comprehensive ComponentCode Code Source

83664 80502 NCCI

83690 83690 BCBST

83695 80500 NCCI

83695 80502 NCCI

83700 80500 NCCI

83700 80502 NCCI

83700 83718 NCCI

83700 83719 NCCI

83700 83721 NCCI

83701 80500 NCCI

83701 80502 NCCI

83701 83700 NCCI

83701 83718 NCCI

83701 83719 NCCI

83701 83721 NCCI

83704 80061 NCCI

83704 80500 NCCI

83704 80502 NCCI

83704 82465 NCCI

83704 83700 NCCI

83704 83701 NCCI

83704 83718 NCCI

83704 83719 NCCI

83704 83721 NCCI

83704 84478 NCCI

83718 80500 NCCI

83718 80502 NCCI

83719 80500 NCCI

83719 80502 NCCI

83721 80500 NCCI

83721 80502 NCCI

83735 83735 BCBST

83788 83788 BCBST

83789 83789 BCBST

83805 83805 BCBST

83835 83835 BCBST

83840 83840 BCBST

83857 83857 BCBST

83858 83858 BCBST

83861 83930 NCCI

83861 83935 NCCI

83872 83872 BCBST

83874 83874 BCBST

83876 83520 NCCI

83876 84311 NCCI

83883 83883 BCBST

83890 83890 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 216 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

83891 83891 BCBST

83892 83892 BCBST

83893 83893 BCBST

83894 83894 BCBST

83896 83896 BCBST

83897 83897 BCBST

83898 83898 BCBST

83901 83901 BCBST

83902 83902 BCBST

83916 80500 NCCI

83916 80502 NCCI

83916 83916 BCBST

83918 83919 NCCI

83921 83919 NCCI

83921 83921 BCBST

83930 83930 BCBST

83935 83935 BCBST

83950 86294 NCCI

83950 86316 NCCI

83950 88271 NCCI

83950 88274 NCCI

83950 88275 NCCI

83951 83520 NCCI

83951 86294 NCCI

83951 86316 NCCI

83986 83986 BCBST

83987 82800 NCCI

83987 83986 NCCI

83987 94250 NCCI

83992 83992 BCBST

84022 84022 BCBST

84061 84061 BCBST

84075 84075 BCBST

84078 84078 BCBST

84080 80500 NCCI

84080 80502 NCCI

84100 84100 BCBST

84105 84105 BCBST

84112 82105 NCCI

84112 82106 NCCI

84112 82107 NCCI

84132 84132 BCBST

84145 83516 NCCI

84145 83518 NCCI

84146 80500 NCCI

84146 80502 NCCI

84146 84146 BCBST

Comprehensive ComponentCode Code Source

84155 84160 NCCI

84160 84156 NCCI

84160 84157 NCCI

84165 80500 NCCI

84165 80502 NCCI

84166 80500 NCCI

84166 80502 NCCI

84181 80500 NCCI

84181 80502 NCCI

84182 80500 NCCI

84182 80502 NCCI

84182 84181 NCCI

84206 84206 BCBST

84207 84591 NCCI

84233 80500 NCCI

84233 80502 NCCI

84234 80500 NCCI

84234 80502 NCCI

84235 80500 NCCI

84235 80502 NCCI

84235 84235 BCBST

84238 80500 NCCI

84238 80502 NCCI

84238 84238 BCBST

84244 80500 NCCI

84244 80502 NCCI

84244 84244 BCBST

84252 84591 NCCI

84295 84295 BCBST

84300 84300 BCBST

84302 84302 BCBST

84305 84305 BCBST

84307 84307 BCBST

84311 84311 BCBST

84315 84315 BCBST

84376 84376 BCBST

84377 84376 NCCI

84377 84377 BCBST

84378 84376 NCCI

84378 84378 BCBST

84379 84376 NCCI

84379 84377 NCCI

84379 84378 NCCI

84379 84379 BCBST

84402 84402 BCBST

84403 80500 NCCI

84403 80502 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 217 of 255

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Comprehensive ComponentCode Code Source

84403 84403 BCBST

84410 84402 NCCI

84410 96523 NCCI

84425 84591 NCCI

84436 80500 NCCI

84436 80502 NCCI

84439 80500 NCCI

84439 80502 NCCI

84439 84436 NCCI

84439 84479 NCCI

84443 80500 NCCI

84443 80502 NCCI

84445 80500 NCCI

84445 80502 NCCI

84446 84591 NCCI

84450 84450 BCBST

84460 84460 BCBST

84466 83550 NCCI

84478 80500 NCCI

84478 80502 NCCI

84479 80500 NCCI

84479 80502 NCCI

84480 80500 NCCI

84480 80502 NCCI

84481 80500 NCCI

84481 80502 NCCI

84481 84480 NCCI

84482 80500 NCCI

84482 80502 NCCI

84484 84484 BCBST

84512 84512 BCBST

84520 84520 BCBST

84525 84525 BCBST

84540 84540 BCBST

84560 84560 BCBST

84577 84577 BCBST

84580 84583 NCCI

84586 84586 BCBST

84588 84588 BCBST

84590 84591 NCCI

84591 84591 BCBST

84597 84591 NCCI

84600 84600 BCBST

84620 80500 NCCI

84620 80502 NCCI

84620 84620 BCBST

84681 80500 NCCI

Comprehensive ComponentCode Code Source

84681 80502 NCCI

84681 84681 BCBST

84702 80500 NCCI

84702 80502 NCCI

84830 84830 BCBST

84999 84999 BCBST

85002 85002 BCBST

85004 85004 BCBST

85004 85008 NCCI

85007 85004 NCCI

85007 85007 BCBST

85008 85007 NCCI

85008 85008 BCBST

85009 85004 NCCI

85013 85013 BCBST

85013 88738 NCCI

85014 85013 NCCI

85014 85014 BCBST

85014 88738 NCCI

85018 85008 NCCI

85018 85018 BCBST

85018 88738 NCCI

85025 85004 NCCI

85025 85007 NCCI

85025 85008 NCCI

85025 85009 NCCI

85025 85013 NCCI

85025 85014 NCCI

85025 85018 NCCI

85025 85025 BCBST

85025 85027 NCCI

85025 85032 NCCI

85025 85041 NCCI

85025 85048 NCCI

85025 85049 NCCI

85025 88738 NCCI

85025 G0306 NCCI

85025 G0307 NCCI

85027 85004 NCCI

85027 85008 NCCI

85027 85013 NCCI

85027 85014 NCCI

85027 85018 NCCI

85027 85027 BCBST

85027 85032 NCCI

85027 85041 NCCI

85027 85048 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 218 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

85027 85049 NCCI

85027 88738 NCCI

85027 G0307 NCCI

85032 85008 NCCI

85041 85032 NCCI

85045 85044 NCCI

85046 85044 NCCI

85046 85045 NCCI

85048 85008 NCCI

85048 85032 NCCI

85048 85048 BCBST

85049 85008 NCCI

85049 85032 NCCI

85049 85049 BCBST

85060 85060 BCBST

85130 80500 NCCI

85130 80502 NCCI

85170 80500 NCCI

85170 80502 NCCI

85175 80500 NCCI

85175 80502 NCCI

85210 80500 NCCI

85210 80502 NCCI

85220 80500 NCCI

85220 80502 NCCI

85230 80500 NCCI

85230 80502 NCCI

85240 80500 NCCI

85240 80502 NCCI

85244 80500 NCCI

85244 80502 NCCI

85245 80500 NCCI

85245 80502 NCCI

85246 80500 NCCI

85246 80502 NCCI

85247 80500 NCCI

85247 80502 NCCI

85250 80500 NCCI

85250 80502 NCCI

85260 80500 NCCI

85260 80502 NCCI

85270 80500 NCCI

85270 80502 NCCI

85280 80500 NCCI

85280 80502 NCCI

85290 80500 NCCI

85290 80502 NCCI

Comprehensive ComponentCode Code Source

85291 80500 NCCI

85291 80502 NCCI

85292 80500 NCCI

85292 80502 NCCI

85293 80500 NCCI

85293 80502 NCCI

85300 80500 NCCI

85300 80502 NCCI

85301 80500 NCCI

85301 80502 NCCI

85302 80500 NCCI

85302 80502 NCCI

85303 80500 NCCI

85303 80502 NCCI

85305 80500 NCCI

85305 80502 NCCI

85306 80500 NCCI

85306 80502 NCCI

85307 80500 NCCI

85307 80502 NCCI

85335 80500 NCCI

85335 80502 NCCI

85335 85335 BCBST

85337 80500 NCCI

85337 80502 NCCI

85345 80500 NCCI

85345 80502 NCCI

85345 85345 BCBST

85347 80500 NCCI

85347 80502 NCCI

85347 85345 NCCI

85347 85347 BCBST

85347 85348 NCCI

85348 80500 NCCI

85348 80502 NCCI

85348 85345 NCCI

85348 85348 BCBST

85360 80500 NCCI

85360 80502 NCCI

85362 80500 NCCI

85362 80502 NCCI

85366 80500 NCCI

85366 80502 NCCI

85370 80500 NCCI

85370 80502 NCCI

85378 80500 NCCI

85378 80502 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 219 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

85379 80500 NCCI

85379 80502 NCCI

85380 85378 NCCI

85380 85379 NCCI

85380 85380 BCBST

85384 80500 NCCI

85384 80502 NCCI

85385 80500 NCCI

85385 80502 NCCI

85390 80500 NCCI

85390 80502 NCCI

85400 80500 NCCI

85400 80502 NCCI

85410 80500 NCCI

85410 80502 NCCI

85415 80500 NCCI

85415 80502 NCCI

85420 80500 NCCI

85420 80502 NCCI

85421 80500 NCCI

85421 80502 NCCI

85441 80500 NCCI

85441 80502 NCCI

85445 80500 NCCI

85445 80502 NCCI

85460 80500 NCCI

85460 80502 NCCI

85461 80500 NCCI

85461 80502 NCCI

85475 80500 NCCI

85475 80502 NCCI

85520 80500 NCCI

85520 80502 NCCI

85525 80500 NCCI

85525 80502 NCCI

85530 80500 NCCI

85530 80502 NCCI

85536 80500 NCCI

85536 80502 NCCI

85540 80500 NCCI

85540 80502 NCCI

85547 80500 NCCI

85547 80502 NCCI

85549 80500 NCCI

85549 80502 NCCI

85555 80500 NCCI

85555 80502 NCCI

Comprehensive ComponentCode Code Source

85557 80500 NCCI

85557 80502 NCCI

85557 85555 NCCI

85576 80500 NCCI

85576 80502 NCCI

85597 80500 NCCI

85597 80502 NCCI

85598 80500 NCCI

85598 80502 NCCI

85598 85730 NCCI

85598 85732 NCCI

85610 80500 NCCI

85610 80502 NCCI

85610 85610 BCBST

85611 80500 NCCI

85611 80502 NCCI

85611 85611 BCBST

85612 80500 NCCI

85612 80502 NCCI

85613 80500 NCCI

85613 80502 NCCI

85635 80500 NCCI

85635 80502 NCCI

85652 85651 NCCI

85660 80500 NCCI

85660 80502 NCCI

85670 80500 NCCI

85670 80502 NCCI

85670 85670 BCBST

85675 80500 NCCI

85675 80502 NCCI

85705 80500 NCCI

85705 80502 NCCI

85730 80500 NCCI

85730 80502 NCCI

85732 80500 NCCI

85732 80502 NCCI

85810 85810 BCBST

85999 85999 BCBST

86001 80500 NCCI

86001 80502 NCCI

86003 86005 BCBST

86021 80500 NCCI

86021 80502 NCCI

86022 80500 NCCI

86022 80502 NCCI

86023 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 220 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

86023 80502 NCCI

86038 80500 NCCI

86038 80502 NCCI

86039 80500 NCCI

86039 80502 NCCI

86060 86063 NCCI

86141 86140 NCCI

86146 86146 BCBST

86152 86255 NCCI

86152 86256 NCCI

86152 86355 NCCI

86152 86356 NCCI

86152 86357 NCCI

86152 86359 NCCI

86152 86360 NCCI

86152 86361 NCCI

86152 86367 NCCI

86152 88184 NCCI

86152 88185 NCCI

86152 88187 NCCI

86152 88188 NCCI

86152 88189 NCCI

86152 88313 NCCI

86152 88342 NCCI

86152 88344 NCCI

86152 88346 NCCI

86152 88358 NCCI

86152 88360 NCCI

86152 88361 NCCI

86153 86355 NCCI

86153 86356 NCCI

86153 86357 NCCI

86153 86359 NCCI

86153 86360 NCCI

86153 86361 NCCI

86153 86367 NCCI

86153 88184 NCCI

86153 88185 NCCI

86153 88187 NCCI

86153 88188 NCCI

86153 88189 NCCI

86153 88313 NCCI

86153 88346 NCCI

86153 88358 NCCI

86153 88360 NCCI

86153 88361 NCCI

86155 86155 BCBST

Comprehensive ComponentCode Code Source

86157 86156 NCCI

86185 80500 NCCI

86185 80502 NCCI

86215 80500 NCCI

86215 80502 NCCI

86225 80500 NCCI

86225 80502 NCCI

86226 80500 NCCI

86226 80502 NCCI

86235 80500 NCCI

86235 80502 NCCI

86255 80500 NCCI

86255 80502 NCCI

86256 80500 NCCI

86256 80502 NCCI

86294 86294 BCBST

86294 86386 NCCI

86300 86294 NCCI

86300 86300 BCBST

86300 86316 NCCI

86301 86294 NCCI

86301 86301 BCBST

86301 86316 NCCI

86304 86294 NCCI

86304 86304 BCBST

86304 86316 NCCI

86316 86294 NCCI

86317 86317 BCBST

86317 86318 NCCI

86318 86318 BCBST

86320 80500 NCCI

86320 80502 NCCI

86325 80500 NCCI

86325 80502 NCCI

86325 86325 BCBST

86327 80500 NCCI

86327 80502 NCCI

86329 80500 NCCI

86329 80502 NCCI

86329 86329 BCBST

86329 86331 NCCI

86331 80500 NCCI

86331 80502 NCCI

86332 86332 BCBST

86334 80500 NCCI

86334 80502 NCCI

86334 86334 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 221 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

86335 80500 NCCI

86335 80502 NCCI

86344 80500 NCCI

86344 80502 NCCI

86352 82397 NCCI

86352 86353 NCCI

86352 86360 NCCI

86353 80500 NCCI

86353 80502 NCCI

86355 80500 NCCI

86355 80502 NCCI

86356 80500 NCCI

86356 80502 NCCI

86357 80500 NCCI

86357 80502 NCCI

86359 80500 NCCI

86359 80502 NCCI

86360 80500 NCCI

86360 80502 NCCI

86360 86361 NCCI

86361 80500 NCCI

86361 80502 NCCI

86367 80500 NCCI

86367 80502 NCCI

86376 80500 NCCI

86376 80502 NCCI

86378 80500 NCCI

86378 80502 NCCI

86382 80500 NCCI

86382 80502 NCCI

86382 86382 BCBST

86384 80500 NCCI

86384 80502 NCCI

86480 86580 NCCI

86480 95017 NCCI

86480 95018 NCCI

86480 95024 NCCI

86480 95027 NCCI

86480 95028 NCCI

86481 86359 NCCI

86481 86480 NCCI

86580 96372 NCCI

86580 96377 NCCI

86780 87285 NCCI

86803 G0472 NCCI

86805 86806 NCCI

86813 86812 NCCI

Comprehensive ComponentCode Code Source

86817 86816 NCCI

86825 86355 NCCI

86825 86356 NCCI

86825 86357 NCCI

86825 86359 NCCI

86825 86360 NCCI

86825 86361 NCCI

86825 86367 NCCI

86825 88184 NCCI

86825 88185 NCCI

86825 88187 NCCI

86825 88188 NCCI

86825 88189 NCCI

86826 86355 NCCI

86826 86356 NCCI

86826 86357 NCCI

86826 86359 NCCI

86826 86360 NCCI

86826 86361 NCCI

86826 86367 NCCI

86826 88184 NCCI

86826 88185 NCCI

86826 88187 NCCI

86826 88188 NCCI

86826 88189 NCCI

86828 86807 NCCI

86828 86808 NCCI

86828 86829 NCCI

86828 88184 NCCI

86828 88185 NCCI

86828 88187 NCCI

86828 88188 NCCI

86828 88189 NCCI

86829 86807 NCCI

86829 86808 NCCI

86829 88184 NCCI

86829 88185 NCCI

86829 88187 NCCI

86829 88188 NCCI

86829 88189 NCCI

86830 86807 NCCI

86830 86808 NCCI

86830 86828 NCCI

86830 86829 NCCI

86830 88184 NCCI

86830 88185 NCCI

86830 88187 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 222 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

86830 88188 NCCI

86830 88189 NCCI

86831 86807 NCCI

86831 86808 NCCI

86831 86828 NCCI

86831 86829 NCCI

86831 88184 NCCI

86831 88185 NCCI

86831 88187 NCCI

86831 88188 NCCI

86831 88189 NCCI

86832 86807 NCCI

86832 86808 NCCI

86832 86828 NCCI

86832 86829 NCCI

86832 86830 NCCI

86832 88184 NCCI

86832 88185 NCCI

86832 88187 NCCI

86832 88188 NCCI

86832 88189 NCCI

86833 86807 NCCI

86833 86808 NCCI

86833 86828 NCCI

86833 86829 NCCI

86833 86831 NCCI

86833 88184 NCCI

86833 88185 NCCI

86833 88187 NCCI

86833 88188 NCCI

86833 88189 NCCI

86834 86807 NCCI

86834 86808 NCCI

86834 88184 NCCI

86834 88185 NCCI

86834 88187 NCCI

86834 88188 NCCI

86834 88189 NCCI

86849 86849 BCBST

86885 86850 NCCI

86890 36000 NCCI

86890 36410 NCCI

86890 80500 NCCI

86890 80502 NCCI

86890 86890 BCBST

86890 99195 NCCI

86891 36000 NCCI

Comprehensive ComponentCode Code Source

86891 36410 NCCI

86891 80500 NCCI

86891 80502 NCCI

86891 86891 BCBST

86891 99195 NCCI

86902 86904 NCCI

86904 86904 BCBST

86910 86910 BCBST

86920 86923 NCCI

86921 86921 BCBST

86921 86923 NCCI

86922 86922 BCBST

86922 86923 NCCI

86927 86927 BCBST

86930 86930 BCBST

86931 86930 NCCI

86931 86931 BCBST

86932 86930 NCCI

86932 86931 NCCI

86932 86932 BCBST

86932 88240 NCCI

86932 88241 NCCI

86940 86940 BCBST

86945 86945 BCBST

86950 36000 NCCI

86950 36410 NCCI

86950 96360 NCCI

86950 96365 NCCI

86970 86970 BCBST

86971 86971 BCBST

86972 86972 BCBST

86975 86975 BCBST

86977 86977 BCBST

86978 86978 BCBST

86985 86985 BCBST

86999 86999 BCBST

87001 87001 BCBST

87003 87003 BCBST

87003 88387 NCCI

87003 88388 NCCI

87015 87015 BCBST

87015 88387 NCCI

87015 88388 NCCI

87040 87040 BCBST

87040 87070 NCCI

87040 87071 NCCI

87040 87073 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 223 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87040 87075 NCCI

87040 88387 NCCI

87040 88388 NCCI

87045 87045 BCBST

87045 87070 NCCI

87045 87071 NCCI

87045 87073 NCCI

87045 88387 NCCI

87045 88388 NCCI

87046 87046 BCBST

87046 87070 NCCI

87046 87071 NCCI

87046 87073 NCCI

87046 87081 NCCI

87046 87084 NCCI

87046 88387 NCCI

87046 88388 NCCI

87070 87070 BCBST

87070 88387 NCCI

87070 88388 NCCI

87071 87070 NCCI

87071 87071 BCBST

87071 87081 NCCI

87071 87084 NCCI

87071 88387 NCCI

87071 88388 NCCI

87073 87070 NCCI

87073 87073 BCBST

87073 87075 NCCI

87073 87081 NCCI

87073 87084 NCCI

87073 88387 NCCI

87073 88388 NCCI

87075 87075 BCBST

87075 88387 NCCI

87075 88388 NCCI

87076 88387 NCCI

87076 88388 NCCI

87077 88387 NCCI

87077 88388 NCCI

87081 87040 NCCI

87081 87045 NCCI

87081 87075 NCCI

87081 87081 BCBST

87081 87084 NCCI

87081 87088 NCCI

87081 88387 NCCI

Comprehensive ComponentCode Code Source

87081 88388 NCCI

87084 87040 NCCI

87084 87045 NCCI

87084 87070 NCCI

87084 87075 NCCI

87084 87084 BCBST

87084 88387 NCCI

87084 88388 NCCI

87086 87070 NCCI

87086 87071 NCCI

87086 87073 NCCI

87086 87075 NCCI

87086 87081 NCCI

87086 87084 NCCI

87086 88387 NCCI

87086 88388 NCCI

87088 87070 NCCI

87088 87071 NCCI

87088 87073 NCCI

87088 87075 NCCI

87088 87084 NCCI

87088 88387 NCCI

87088 88388 NCCI

87101 87101 BCBST

87101 88387 NCCI

87101 88388 NCCI

87102 87102 BCBST

87102 88387 NCCI

87102 88388 NCCI

87103 87103 BCBST

87103 88387 NCCI

87103 88388 NCCI

87106 87107 NCCI

87106 88387 NCCI

87106 88388 NCCI

87107 88387 NCCI

87107 88388 NCCI

87109 88387 NCCI

87109 88388 NCCI

87110 88387 NCCI

87110 88388 NCCI

87116 87116 BCBST

87116 88387 NCCI

87116 88388 NCCI

87118 88387 NCCI

87118 88388 NCCI

87140 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 224 of 255

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Comprehensive ComponentCode Code Source

87140 80502 NCCI

87140 81400 NCCI

87140 81401 NCCI

87140 81402 NCCI

87140 81403 NCCI

87140 81404 NCCI

87140 81405 NCCI

87140 81406 NCCI

87140 81407 NCCI

87140 81408 NCCI

87140 87147 NCCI

87140 87149 NCCI

87140 87150 NCCI

87140 87153 NCCI

87140 87260 NCCI

87140 87265 NCCI

87140 87267 NCCI

87140 87269 NCCI

87140 87270 NCCI

87140 87271 NCCI

87140 87272 NCCI

87140 87274 NCCI

87140 87276 NCCI

87140 87278 NCCI

87140 87280 NCCI

87140 87285 NCCI

87140 87290 NCCI

87140 87299 NCCI

87140 88387 NCCI

87140 88388 NCCI

87143 81400 NCCI

87143 81401 NCCI

87143 81402 NCCI

87143 81403 NCCI

87143 81404 NCCI

87143 81405 NCCI

87143 81406 NCCI

87143 81407 NCCI

87143 81408 NCCI

87143 87140 NCCI

87143 87143 BCBST

87143 87149 NCCI

87143 87150 NCCI

87143 87153 NCCI

87143 88387 NCCI

87143 88388 NCCI

87147 81400 NCCI

Comprehensive ComponentCode Code Source

87147 81401 NCCI

87147 81402 NCCI

87147 81403 NCCI

87147 81404 NCCI

87147 81405 NCCI

87147 81406 NCCI

87147 81407 NCCI

87147 81408 NCCI

87147 86329 NCCI

87147 86331 NCCI

87147 87143 NCCI

87147 87149 NCCI

87147 87150 NCCI

87147 87152 NCCI

87147 87153 NCCI

87147 87158 NCCI

87147 87301 NCCI

87147 87305 NCCI

87147 87320 NCCI

87147 87324 NCCI

87147 87328 NCCI

87147 87329 NCCI

87147 87332 NCCI

87147 87335 NCCI

87147 87338 NCCI

87147 87340 NCCI

87147 87350 NCCI

87147 87380 NCCI

87147 87385 NCCI

87147 87389 NCCI

87147 87390 NCCI

87147 87391 NCCI

87147 87420 NCCI

87147 87425 NCCI

87147 87430 NCCI

87147 87449 NCCI

87147 87450 NCCI

87147 87807 NCCI

87147 87810 NCCI

87147 87850 NCCI

87147 87880 NCCI

87147 87899 NCCI

87147 88387 NCCI

87147 88388 NCCI

87149 80500 NCCI

87149 80502 NCCI

87149 81400 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 225 of 255

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Comprehensive ComponentCode Code Source

87149 81401 NCCI

87149 81402 NCCI

87149 81403 NCCI

87149 81404 NCCI

87149 81405 NCCI

87149 81406 NCCI

87149 81407 NCCI

87149 81408 NCCI

87149 87149 BCBST

87149 87470 NCCI

87149 87471 NCCI

87149 87472 NCCI

87149 87475 NCCI

87149 87476 NCCI

87149 87477 NCCI

87149 87480 NCCI

87149 87481 NCCI

87149 87482 NCCI

87149 87483 NCCI

87149 87485 NCCI

87149 87486 NCCI

87149 87487 NCCI

87149 87490 NCCI

87149 87491 NCCI

87149 87492 NCCI

87149 87495 NCCI

87149 87496 NCCI

87149 87497 NCCI

87149 87498 NCCI

87149 87510 NCCI

87149 87511 NCCI

87149 87512 NCCI

87149 87515 NCCI

87149 87516 NCCI

87149 87517 NCCI

87149 87520 NCCI

87149 87521 NCCI

87149 87522 NCCI

87149 87525 NCCI

87149 87526 NCCI

87149 87527 NCCI

87149 87528 NCCI

87149 87529 NCCI

87149 87530 NCCI

87149 87531 NCCI

87149 87532 NCCI

87149 87533 NCCI

Comprehensive ComponentCode Code Source

87149 87534 NCCI

87149 87535 NCCI

87149 87536 NCCI

87149 87537 NCCI

87149 87538 NCCI

87149 87539 NCCI

87149 87540 NCCI

87149 87541 NCCI

87149 87542 NCCI

87149 87550 NCCI

87149 87551 NCCI

87149 87552 NCCI

87149 87555 NCCI

87149 87556 NCCI

87149 87557 NCCI

87149 87560 NCCI

87149 87561 NCCI

87149 87562 NCCI

87149 87580 NCCI

87149 87581 NCCI

87149 87582 NCCI

87149 87590 NCCI

87149 87591 NCCI

87149 87592 NCCI

87149 87640 NCCI

87149 87641 NCCI

87149 87650 NCCI

87149 87651 NCCI

87149 87652 NCCI

87149 87653 NCCI

87149 87660 NCCI

87149 87661 NCCI

87149 87797 NCCI

87149 87798 NCCI

87149 87799 NCCI

87149 88387 NCCI

87149 88388 NCCI

87150 80500 NCCI

87150 80502 NCCI

87150 81400 NCCI

87150 81401 NCCI

87150 81402 NCCI

87150 81403 NCCI

87150 81404 NCCI

87150 81405 NCCI

87150 81406 NCCI

87150 81407 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 226 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87150 81408 NCCI

87150 87149 NCCI

87150 87470 NCCI

87150 87471 NCCI

87150 87472 NCCI

87150 87475 NCCI

87150 87476 NCCI

87150 87477 NCCI

87150 87480 NCCI

87150 87481 NCCI

87150 87482 NCCI

87150 87483 NCCI

87150 87485 NCCI

87150 87486 NCCI

87150 87487 NCCI

87150 87490 NCCI

87150 87491 NCCI

87150 87492 NCCI

87150 87495 NCCI

87150 87496 NCCI

87150 87497 NCCI

87150 87498 NCCI

87150 87510 NCCI

87150 87511 NCCI

87150 87512 NCCI

87150 87515 NCCI

87150 87516 NCCI

87150 87517 NCCI

87150 87520 NCCI

87150 87521 NCCI

87150 87522 NCCI

87150 87525 NCCI

87150 87526 NCCI

87150 87527 NCCI

87150 87528 NCCI

87150 87529 NCCI

87150 87530 NCCI

87150 87531 NCCI

87150 87532 NCCI

87150 87533 NCCI

87150 87534 NCCI

87150 87535 NCCI

87150 87536 NCCI

87150 87537 NCCI

87150 87538 NCCI

87150 87539 NCCI

87150 87540 NCCI

Comprehensive ComponentCode Code Source

87150 87541 NCCI

87150 87542 NCCI

87150 87550 NCCI

87150 87551 NCCI

87150 87552 NCCI

87150 87555 NCCI

87150 87556 NCCI

87150 87557 NCCI

87150 87560 NCCI

87150 87561 NCCI

87150 87562 NCCI

87150 87580 NCCI

87150 87581 NCCI

87150 87582 NCCI

87150 87590 NCCI

87150 87591 NCCI

87150 87592 NCCI

87150 87640 NCCI

87150 87641 NCCI

87150 87650 NCCI

87150 87651 NCCI

87150 87652 NCCI

87150 87653 NCCI

87150 87660 NCCI

87150 87661 NCCI

87150 87797 NCCI

87150 87798 NCCI

87150 87799 NCCI

87152 81400 NCCI

87152 81401 NCCI

87152 81402 NCCI

87152 81403 NCCI

87152 81404 NCCI

87152 81405 NCCI

87152 81406 NCCI

87152 81407 NCCI

87152 81408 NCCI

87152 87140 NCCI

87152 87143 NCCI

87152 87149 NCCI

87152 87150 NCCI

87152 87152 BCBST

87152 87153 NCCI

87152 87158 NCCI

87152 88387 NCCI

87152 88388 NCCI

87153 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 227 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87153 80502 NCCI

87153 81400 NCCI

87153 81401 NCCI

87153 81402 NCCI

87153 81403 NCCI

87153 81404 NCCI

87153 81405 NCCI

87153 81406 NCCI

87153 81407 NCCI

87153 81408 NCCI

87153 87149 NCCI

87153 87150 NCCI

87153 87470 NCCI

87153 87471 NCCI

87153 87472 NCCI

87153 87475 NCCI

87153 87476 NCCI

87153 87477 NCCI

87153 87480 NCCI

87153 87481 NCCI

87153 87482 NCCI

87153 87483 NCCI

87153 87485 NCCI

87153 87486 NCCI

87153 87487 NCCI

87153 87490 NCCI

87153 87491 NCCI

87153 87492 NCCI

87153 87495 NCCI

87153 87496 NCCI

87153 87497 NCCI

87153 87498 NCCI

87153 87501 NCCI

87153 87502 NCCI

87153 87510 NCCI

87153 87511 NCCI

87153 87512 NCCI

87153 87515 NCCI

87153 87516 NCCI

87153 87517 NCCI

87153 87520 NCCI

87153 87521 NCCI

87153 87522 NCCI

87153 87525 NCCI

87153 87526 NCCI

87153 87527 NCCI

87153 87528 NCCI

Comprehensive ComponentCode Code Source

87153 87529 NCCI

87153 87530 NCCI

87153 87531 NCCI

87153 87532 NCCI

87153 87533 NCCI

87153 87534 NCCI

87153 87535 NCCI

87153 87536 NCCI

87153 87537 NCCI

87153 87538 NCCI

87153 87539 NCCI

87153 87540 NCCI

87153 87541 NCCI

87153 87542 NCCI

87153 87550 NCCI

87153 87551 NCCI

87153 87552 NCCI

87153 87555 NCCI

87153 87556 NCCI

87153 87557 NCCI

87153 87560 NCCI

87153 87561 NCCI

87153 87562 NCCI

87153 87580 NCCI

87153 87581 NCCI

87153 87582 NCCI

87153 87590 NCCI

87153 87591 NCCI

87153 87592 NCCI

87153 87640 NCCI

87153 87641 NCCI

87153 87650 NCCI

87153 87651 NCCI

87153 87652 NCCI

87153 87653 NCCI

87153 87660 NCCI

87153 87661 NCCI

87153 87797 NCCI

87153 87798 NCCI

87153 87799 NCCI

87158 81400 NCCI

87158 81401 NCCI

87158 81402 NCCI

87158 81403 NCCI

87158 81404 NCCI

87158 81405 NCCI

87158 81406 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 228 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87158 81407 NCCI

87158 81408 NCCI

87158 87140 NCCI

87158 87143 NCCI

87158 87149 NCCI

87158 87150 NCCI

87158 87153 NCCI

87158 87158 BCBST

87158 88387 NCCI

87158 88388 NCCI

87164 80500 NCCI

87164 80502 NCCI

87164 87166 NCCI

87164 88387 NCCI

87164 88388 NCCI

87166 80500 NCCI

87166 80502 NCCI

87166 88387 NCCI

87166 88388 NCCI

87168 80500 NCCI

87168 80502 NCCI

87168 88300 NCCI

87168 88387 NCCI

87168 88388 NCCI

87169 80500 NCCI

87169 80502 NCCI

87169 88300 NCCI

87169 88387 NCCI

87169 88388 NCCI

87172 80500 NCCI

87172 80502 NCCI

87172 88300 NCCI

87172 88302 NCCI

87172 88304 NCCI

87172 88305 NCCI

87172 88387 NCCI

87172 88388 NCCI

87172 G0416 NCCI

87176 88387 NCCI

87176 88388 NCCI

87177 80500 NCCI

87177 80502 NCCI

87177 87015 NCCI

87177 87177 BCBST

87177 88387 NCCI

87177 88388 NCCI

87181 87184 NCCI

Comprehensive ComponentCode Code Source

87181 87185 NCCI

87181 87186 NCCI

87181 87188 NCCI

87181 87190 NCCI

87181 88387 NCCI

87181 88388 NCCI

87184 87186 NCCI

87184 87188 NCCI

87184 87190 NCCI

87184 88387 NCCI

87184 88388 NCCI

87185 87184 NCCI

87185 87186 NCCI

87185 87188 NCCI

87185 87190 NCCI

87185 88387 NCCI

87185 88388 NCCI

87186 87186 BCBST

87186 87188 NCCI

87186 87190 NCCI

87186 88387 NCCI

87186 88388 NCCI

87187 87187 BCBST

87187 88387 NCCI

87187 88388 NCCI

87188 87190 NCCI

87188 88387 NCCI

87188 88388 NCCI

87190 88387 NCCI

87190 88388 NCCI

87197 87197 BCBST

87197 88387 NCCI

87197 88388 NCCI

87205 80500 NCCI

87205 80502 NCCI

87205 87205 BCBST

87205 88387 NCCI

87205 88388 NCCI

87206 80500 NCCI

87206 80502 NCCI

87206 87177 NCCI

87206 87206 BCBST

87206 88387 NCCI

87206 88388 NCCI

87207 80500 NCCI

87207 80502 NCCI

87207 87177 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 229 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87207 87207 BCBST

87207 88387 NCCI

87207 88388 NCCI

87209 80500 NCCI

87209 80502 NCCI

87209 87207 NCCI

87209 88387 NCCI

87209 88388 NCCI

87210 80500 NCCI

87210 80502 NCCI

87210 87177 NCCI

87210 87210 BCBST

87210 88387 NCCI

87210 88388 NCCI

87220 80500 NCCI

87220 80502 NCCI

87220 87177 NCCI

87220 87220 BCBST

87220 88387 NCCI

87220 88388 NCCI

87230 87230 BCBST

87230 88387 NCCI

87230 88388 NCCI

87250 87250 BCBST

87250 88387 NCCI

87250 88388 NCCI

87252 87252 BCBST

87252 88387 NCCI

87252 88388 NCCI

87253 87260 NCCI

87253 87267 NCCI

87253 87271 NCCI

87253 87274 NCCI

87253 87276 NCCI

87253 87280 NCCI

87253 87290 NCCI

87253 87301 NCCI

87253 87305 NCCI

87253 87332 NCCI

87253 87340 NCCI

87253 87350 NCCI

87253 87380 NCCI

87253 87389 NCCI

87253 87390 NCCI

87253 87391 NCCI

87253 87420 NCCI

87253 87425 NCCI

Comprehensive ComponentCode Code Source

87253 87483 NCCI

87253 87495 NCCI

87253 87496 NCCI

87253 87497 NCCI

87253 87498 NCCI

87253 87515 NCCI

87253 87516 NCCI

87253 87517 NCCI

87253 87520 NCCI

87253 87521 NCCI

87253 87522 NCCI

87253 87525 NCCI

87253 87526 NCCI

87253 87527 NCCI

87253 87528 NCCI

87253 87529 NCCI

87253 87530 NCCI

87253 87531 NCCI

87253 87532 NCCI

87253 87533 NCCI

87253 87534 NCCI

87253 87535 NCCI

87253 87536 NCCI

87253 87537 NCCI

87253 87538 NCCI

87253 87539 NCCI

87253 87623 NCCI

87253 87624 NCCI

87253 87625 NCCI

87253 87640 NCCI

87253 87641 NCCI

87253 87653 NCCI

87253 88387 NCCI

87253 88388 NCCI

87253 G0476 NCCI

87254 87253 NCCI

87254 87260 NCCI

87254 87267 NCCI

87254 87271 NCCI

87254 87274 NCCI

87254 87276 NCCI

87254 87280 NCCI

87254 87290 NCCI

87254 88387 NCCI

87254 88388 NCCI

87255 87253 NCCI

87255 87254 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 230 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87255 87255 BCBST

87255 88387 NCCI

87255 88388 NCCI

87260 80500 NCCI

87260 80502 NCCI

87260 87206 NCCI

87260 87301 NCCI

87260 87809 NCCI

87260 88346 NCCI

87265 80500 NCCI

87265 80502 NCCI

87265 88346 NCCI

87267 80500 NCCI

87267 80502 NCCI

87267 87206 NCCI

87267 88346 NCCI

87269 80500 NCCI

87269 80502 NCCI

87269 87206 NCCI

87269 87329 NCCI

87269 88346 NCCI

87270 80500 NCCI

87270 80502 NCCI

87270 87320 NCCI

87270 87490 NCCI

87270 87491 NCCI

87270 87492 NCCI

87270 88346 NCCI

87271 80500 NCCI

87271 80502 NCCI

87271 87332 Reversed NCCI

87271 88346 NCCI

87272 80500 NCCI

87272 80502 NCCI

87272 87206 NCCI

87272 87328 NCCI

87272 88346 NCCI

87273 80500 NCCI

87273 80502 NCCI

87273 87206 NCCI

87273 87528 NCCI

87273 87529 NCCI

87273 87530 NCCI

87273 88346 NCCI

87274 80500 NCCI

87274 80502 NCCI

87274 87206 NCCI

Comprehensive ComponentCode Code Source

87274 87528 NCCI

87274 87529 NCCI

87274 87530 NCCI

87274 88346 NCCI

87275 80500 NCCI

87275 80502 NCCI

87275 87206 NCCI

87275 87400 NCCI

87275 87804 NCCI

87275 88346 NCCI

87276 80500 NCCI

87276 80502 NCCI

87276 87206 NCCI

87276 87400 NCCI

87276 87804 NCCI

87276 88346 NCCI

87277 80500 NCCI

87277 80502 NCCI

87277 87206 NCCI

87277 88346 NCCI

87278 80500 NCCI

87278 80502 NCCI

87278 87206 NCCI

87278 87540 NCCI

87278 87541 NCCI

87278 87542 NCCI

87278 88346 NCCI

87279 80500 NCCI

87279 80502 NCCI

87279 87206 NCCI

87279 88346 NCCI

87280 80500 NCCI

87280 80502 NCCI

87280 87206 NCCI

87280 87420 NCCI

87280 88346 NCCI

87281 80500 NCCI

87281 80502 NCCI

87281 87206 NCCI

87281 88346 NCCI

87283 80500 NCCI

87283 80502 NCCI

87283 87206 NCCI

87283 88346 NCCI

87285 80500 NCCI

87285 80502 NCCI

87285 88346 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 231 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87290 80500 NCCI

87290 80502 NCCI

87290 87206 NCCI

87290 88346 NCCI

87299 80500 NCCI

87299 80502 NCCI

87299 87206 NCCI

87299 88346 NCCI

87300 80500 NCCI

87300 80502 NCCI

87300 87206 NCCI

87320 87490 NCCI

87320 87491 NCCI

87320 87492 NCCI

87324 87206 NCCI

87324 87803 NCCI

87324 88346 NCCI

87328 87206 NCCI

87329 87206 NCCI

87329 88346 NCCI

87332 87495 NCCI

87332 87496 NCCI

87332 87497 NCCI

87338 78268 NCCI

87338 83013 NCCI

87338 87206 NCCI

87338 88346 NCCI

87339 78268 NCCI

87339 83013 NCCI

87339 87338 NCCI

87350 87206 NCCI

87389 86701 NCCI

87389 86702 NCCI

87389 86703 NCCI

87389 87390 NCCI

87389 87534 NCCI

87389 87535 NCCI

87390 87535 NCCI

87400 87804 NCCI

87425 87206 NCCI

87430 87650 NCCI

87430 87651 NCCI

87430 87652 NCCI

87430 87880 NCCI

87449 87450 NCCI

87470 80500 NCCI

87470 80502 NCCI

Comprehensive ComponentCode Code Source

87470 81400 NCCI

87470 81401 NCCI

87470 81402 NCCI

87470 81403 NCCI

87470 81404 NCCI

87470 81405 NCCI

87470 81406 NCCI

87470 81407 NCCI

87470 81408 NCCI

87470 87471 NCCI

87470 87472 NCCI

87471 80500 NCCI

87471 80502 NCCI

87471 81400 NCCI

87471 81401 NCCI

87471 81402 NCCI

87471 81403 NCCI

87471 81404 NCCI

87471 81405 NCCI

87471 81406 NCCI

87471 81407 NCCI

87471 81408 NCCI

87471 87472 NCCI

87472 80500 NCCI

87472 80502 NCCI

87472 81400 NCCI

87472 81401 NCCI

87472 81402 NCCI

87472 81403 NCCI

87472 81404 NCCI

87472 81405 NCCI

87472 81406 NCCI

87472 81407 NCCI

87472 81408 NCCI

87475 80500 NCCI

87475 80502 NCCI

87475 81400 NCCI

87475 81401 NCCI

87475 81402 NCCI

87475 81403 NCCI

87475 81404 NCCI

87475 81405 NCCI

87475 81406 NCCI

87475 81407 NCCI

87475 81408 NCCI

87475 87476 NCCI

87475 87477 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 232 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87476 80500 NCCI

87476 80502 NCCI

87476 81400 NCCI

87476 81401 NCCI

87476 81402 NCCI

87476 81403 NCCI

87476 81404 NCCI

87476 81405 NCCI

87476 81406 NCCI

87476 81407 NCCI

87476 81408 NCCI

87476 87206 NCCI

87476 87477 NCCI

87477 80500 NCCI

87477 80502 NCCI

87477 81400 NCCI

87477 81401 NCCI

87477 81402 NCCI

87477 81403 NCCI

87477 81404 NCCI

87477 81405 NCCI

87477 81406 NCCI

87477 81407 NCCI

87477 81408 NCCI

87480 80500 NCCI

87480 80502 NCCI

87480 81400 NCCI

87480 81401 NCCI

87480 81402 NCCI

87480 81403 NCCI

87480 81404 NCCI

87480 81405 NCCI

87480 81406 NCCI

87480 81407 NCCI

87480 81408 NCCI

87480 87449 NCCI

87480 87481 NCCI

87480 87482 NCCI

87481 80500 NCCI

87481 80502 NCCI

87481 81400 NCCI

87481 81401 NCCI

87481 81402 NCCI

87481 81403 NCCI

87481 81404 NCCI

87481 81405 NCCI

87481 81406 NCCI

Comprehensive ComponentCode Code Source

87481 81407 NCCI

87481 81408 NCCI

87481 87482 NCCI

87482 80500 NCCI

87482 80502 NCCI

87482 81400 NCCI

87482 81401 NCCI

87482 81402 NCCI

87482 81403 NCCI

87482 81404 NCCI

87482 81405 NCCI

87482 81406 NCCI

87482 81407 NCCI

87482 81408 NCCI

87483 80500 NCCI

87483 80502 NCCI

87483 81400 NCCI

87483 81401 NCCI

87483 81402 NCCI

87483 81403 NCCI

87483 81404 NCCI

87483 81405 NCCI

87483 81406 NCCI

87483 81407 NCCI

87483 81408 NCCI

87483 87267 NCCI

87483 87271 NCCI

87483 87273 NCCI

87483 87274 NCCI

87483 87290 NCCI

87483 87327 NCCI

87483 87332 NCCI

87483 87335 NCCI

87483 87495 NCCI

87483 87496 NCCI

87483 87497 NCCI

87483 87528 NCCI

87483 87529 NCCI

87483 87530 NCCI

87483 87531 NCCI

87483 87532 NCCI

87483 87533 NCCI

87483 87653 NCCI

87483 87801 NCCI

87483 87802 NCCI

87483 96523 NCCI

87485 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 233 of 255

Page 234: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87485 80502 NCCI

87485 81400 NCCI

87485 81401 NCCI

87485 81402 NCCI

87485 81403 NCCI

87485 81404 NCCI

87485 81405 NCCI

87485 81406 NCCI

87485 81407 NCCI

87485 81408 NCCI

87485 87486 NCCI

87485 87487 NCCI

87486 80500 NCCI

87486 80502 NCCI

87486 81400 NCCI

87486 81401 NCCI

87486 81402 NCCI

87486 81403 NCCI

87486 81404 NCCI

87486 81405 NCCI

87486 81406 NCCI

87486 81407 NCCI

87486 81408 NCCI

87486 87487 NCCI

87487 80500 NCCI

87487 80502 NCCI

87487 81400 NCCI

87487 81401 NCCI

87487 81402 NCCI

87487 81403 NCCI

87487 81404 NCCI

87487 81405 NCCI

87487 81406 NCCI

87487 81407 NCCI

87487 81408 NCCI

87490 80500 NCCI

87490 80502 NCCI

87490 81400 NCCI

87490 81401 NCCI

87490 81402 NCCI

87490 81403 NCCI

87490 81404 NCCI

87490 81405 NCCI

87490 81406 NCCI

87490 81407 NCCI

87490 81408 NCCI

87490 87206 NCCI

Comprehensive ComponentCode Code Source

87490 87491 NCCI

87490 87492 NCCI

87491 80500 NCCI

87491 80502 NCCI

87491 81400 NCCI

87491 81401 NCCI

87491 81402 NCCI

87491 81403 NCCI

87491 81404 NCCI

87491 81405 NCCI

87491 81406 NCCI

87491 81407 NCCI

87491 81408 NCCI

87491 87492 NCCI

87492 80500 NCCI

87492 80502 NCCI

87492 81400 NCCI

87492 81401 NCCI

87492 81402 NCCI

87492 81403 NCCI

87492 81404 NCCI

87492 81405 NCCI

87492 81406 NCCI

87492 81407 NCCI

87492 81408 NCCI

87493 80500 NCCI

87493 80502 NCCI

87493 81400 NCCI

87493 81401 NCCI

87493 81402 NCCI

87493 81403 NCCI

87493 81404 NCCI

87493 81405 NCCI

87493 81406 NCCI

87493 81407 NCCI

87493 81408 NCCI

87493 87149 NCCI

87493 87324 NCCI

87493 87803 NCCI

87495 80500 NCCI

87495 80502 NCCI

87495 81400 NCCI

87495 81401 NCCI

87495 81402 NCCI

87495 81403 NCCI

87495 81404 NCCI

87495 81405 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 234 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87495 81406 NCCI

87495 81407 NCCI

87495 81408 NCCI

87495 87271 NCCI

87495 87496 NCCI

87495 87497 NCCI

87496 80500 NCCI

87496 80502 NCCI

87496 81400 NCCI

87496 81401 NCCI

87496 81402 NCCI

87496 81403 NCCI

87496 81404 NCCI

87496 81405 NCCI

87496 81406 NCCI

87496 81407 NCCI

87496 81408 NCCI

87496 87206 NCCI

87496 87271 NCCI

87496 87497 NCCI

87497 80500 NCCI

87497 80502 NCCI

87497 81400 NCCI

87497 81401 NCCI

87497 81402 NCCI

87497 81403 NCCI

87497 81404 NCCI

87497 81405 NCCI

87497 81406 NCCI

87497 81407 NCCI

87497 81408 NCCI

87497 87271 NCCI

87498 80500 NCCI

87498 80502 NCCI

87498 81400 NCCI

87498 81401 NCCI

87498 81402 NCCI

87498 81403 NCCI

87498 81404 NCCI

87498 81405 NCCI

87498 81406 NCCI

87498 81407 NCCI

87498 81408 NCCI

87498 87267 NCCI

87500 80500 NCCI

87500 80502 NCCI

87500 81400 NCCI

Comprehensive ComponentCode Code Source

87500 81401 NCCI

87500 81402 NCCI

87500 81403 NCCI

87500 81404 NCCI

87500 81405 NCCI

87500 81406 NCCI

87500 81407 NCCI

87500 81408 NCCI

87500 87149 NCCI

87500 87150 NCCI

87500 87153 NCCI

87500 87253 NCCI

87501 80500 NCCI

87501 80502 NCCI

87501 81400 NCCI

87501 81401 NCCI

87501 81402 NCCI

87501 81403 NCCI

87501 81404 NCCI

87501 81405 NCCI

87501 81406 NCCI

87501 81407 NCCI

87501 81408 NCCI

87501 87149 NCCI

87501 87150 NCCI

87501 87253 NCCI

87501 87275 NCCI

87501 87276 NCCI

87501 87400 NCCI

87501 87804 NCCI

87502 80500 NCCI

87502 80502 NCCI

87502 81400 NCCI

87502 81401 NCCI

87502 81402 NCCI

87502 81403 NCCI

87502 81404 NCCI

87502 81405 NCCI

87502 81406 NCCI

87502 81407 NCCI

87502 81408 NCCI

87502 87149 NCCI

87502 87150 NCCI

87502 87253 NCCI

87502 87275 NCCI

87502 87276 NCCI

87502 87277 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 235 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87502 87501 NCCI

87502 87804 NCCI

87503 81400 NCCI

87503 81401 NCCI

87503 81402 NCCI

87503 81403 NCCI

87503 81404 NCCI

87503 81405 NCCI

87503 81406 NCCI

87503 81407 NCCI

87503 81408 NCCI

87505 87269 NCCI

87505 87324 NCCI

87505 87329 NCCI

87505 87335 NCCI

87505 87427 NCCI

87505 87493 NCCI

87505 87801 NCCI

87505 87803 NCCI

87506 87269 NCCI

87506 87324 NCCI

87506 87329 NCCI

87506 87335 NCCI

87506 87427 NCCI

87506 87493 NCCI

87506 87505 NCCI

87506 87801 NCCI

87506 87803 NCCI

87507 87269 NCCI

87507 87324 NCCI

87507 87329 NCCI

87507 87335 NCCI

87507 87427 NCCI

87507 87493 NCCI

87507 87505 NCCI

87507 87506 NCCI

87507 87801 NCCI

87507 87803 NCCI

87510 80500 NCCI

87510 80502 NCCI

87510 81400 NCCI

87510 81401 NCCI

87510 81402 NCCI

87510 81403 NCCI

87510 81404 NCCI

87510 81405 NCCI

87510 81406 NCCI

Comprehensive ComponentCode Code Source

87510 81407 NCCI

87510 81408 NCCI

87510 87511 NCCI

87510 87512 NCCI

87511 80500 NCCI

87511 80502 NCCI

87511 81400 NCCI

87511 81401 NCCI

87511 81402 NCCI

87511 81403 NCCI

87511 81404 NCCI

87511 81405 NCCI

87511 81406 NCCI

87511 81407 NCCI

87511 81408 NCCI

87511 87512 NCCI

87512 80500 NCCI

87512 80502 NCCI

87512 81400 NCCI

87512 81401 NCCI

87512 81402 NCCI

87512 81403 NCCI

87512 81404 NCCI

87512 81405 NCCI

87512 81406 NCCI

87512 81407 NCCI

87512 81408 NCCI

87515 80500 NCCI

87515 80502 NCCI

87515 81400 NCCI

87515 81401 NCCI

87515 81402 NCCI

87515 81403 NCCI

87515 81404 NCCI

87515 81405 NCCI

87515 81406 NCCI

87515 81407 NCCI

87515 81408 NCCI

87515 87516 NCCI

87515 87517 NCCI

87516 80500 NCCI

87516 80502 NCCI

87516 81400 NCCI

87516 81401 NCCI

87516 81402 NCCI

87516 81403 NCCI

87516 81404 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 236 of 255

Page 237: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87516 81405 NCCI

87516 81406 NCCI

87516 81407 NCCI

87516 81408 NCCI

87516 87517 NCCI

87517 80500 NCCI

87517 80502 NCCI

87517 81400 NCCI

87517 81401 NCCI

87517 81402 NCCI

87517 81403 NCCI

87517 81404 NCCI

87517 81405 NCCI

87517 81406 NCCI

87517 81407 NCCI

87517 81408 NCCI

87520 80500 NCCI

87520 80502 NCCI

87520 81400 NCCI

87520 81401 NCCI

87520 81402 NCCI

87520 81403 NCCI

87520 81404 NCCI

87520 81405 NCCI

87520 81406 NCCI

87520 81407 NCCI

87520 81408 NCCI

87520 87449 NCCI

87520 87521 NCCI

87520 87522 NCCI

87521 80500 NCCI

87521 80502 NCCI

87521 81400 NCCI

87521 81401 NCCI

87521 81402 NCCI

87521 81403 NCCI

87521 81404 NCCI

87521 81405 NCCI

87521 81406 NCCI

87521 81407 NCCI

87521 81408 NCCI

87521 87449 NCCI

87521 87522 NCCI

87522 80500 NCCI

87522 80502 NCCI

87522 81400 NCCI

87522 81401 NCCI

Comprehensive ComponentCode Code Source

87522 81402 NCCI

87522 81403 NCCI

87522 81404 NCCI

87522 81405 NCCI

87522 81406 NCCI

87522 81407 NCCI

87522 81408 NCCI

87525 80500 NCCI

87525 80502 NCCI

87525 81400 NCCI

87525 81401 NCCI

87525 81402 NCCI

87525 81403 NCCI

87525 81404 NCCI

87525 81405 NCCI

87525 81406 NCCI

87525 81407 NCCI

87525 81408 NCCI

87525 87526 NCCI

87525 87527 NCCI

87526 80500 NCCI

87526 80502 NCCI

87526 81400 NCCI

87526 81401 NCCI

87526 81402 NCCI

87526 81403 NCCI

87526 81404 NCCI

87526 81405 NCCI

87526 81406 NCCI

87526 81407 NCCI

87526 81408 NCCI

87526 87527 NCCI

87527 80500 NCCI

87527 80502 NCCI

87527 81400 NCCI

87527 81401 NCCI

87527 81402 NCCI

87527 81403 NCCI

87527 81404 NCCI

87527 81405 NCCI

87527 81406 NCCI

87527 81407 NCCI

87527 81408 NCCI

87528 80500 NCCI

87528 80502 NCCI

87528 81400 NCCI

87528 81401 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 237 of 255

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BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87528 81402 NCCI

87528 81403 NCCI

87528 81404 NCCI

87528 81405 NCCI

87528 81406 NCCI

87528 81407 NCCI

87528 81408 NCCI

87528 87529 NCCI

87528 87530 NCCI

87529 80500 NCCI

87529 80502 NCCI

87529 81400 NCCI

87529 81401 NCCI

87529 81402 NCCI

87529 81403 NCCI

87529 81404 NCCI

87529 81405 NCCI

87529 81406 NCCI

87529 81407 NCCI

87529 81408 NCCI

87529 87206 NCCI

87529 87530 NCCI

87530 80500 NCCI

87530 80502 NCCI

87530 81400 NCCI

87530 81401 NCCI

87530 81402 NCCI

87530 81403 NCCI

87530 81404 NCCI

87530 81405 NCCI

87530 81406 NCCI

87530 81407 NCCI

87530 81408 NCCI

87531 80500 NCCI

87531 80502 NCCI

87531 81400 NCCI

87531 81401 NCCI

87531 81402 NCCI

87531 81403 NCCI

87531 81404 NCCI

87531 81405 NCCI

87531 81406 NCCI

87531 81407 NCCI

87531 81408 NCCI

87531 87532 NCCI

87531 87533 NCCI

87532 80500 NCCI

Comprehensive ComponentCode Code Source

87532 80502 NCCI

87532 81400 NCCI

87532 81401 NCCI

87532 81402 NCCI

87532 81403 NCCI

87532 81404 NCCI

87532 81405 NCCI

87532 81406 NCCI

87532 81407 NCCI

87532 81408 NCCI

87532 87533 NCCI

87533 80500 NCCI

87533 80502 NCCI

87533 81400 NCCI

87533 81401 NCCI

87533 81402 NCCI

87533 81403 NCCI

87533 81404 NCCI

87533 81405 NCCI

87533 81406 NCCI

87533 81407 NCCI

87533 81408 NCCI

87534 80500 NCCI

87534 80502 NCCI

87534 81400 NCCI

87534 81401 NCCI

87534 81402 NCCI

87534 81403 NCCI

87534 81404 NCCI

87534 81405 NCCI

87534 81406 NCCI

87534 81407 NCCI

87534 81408 NCCI

87534 87535 NCCI

87534 87536 NCCI

87535 80500 NCCI

87535 80502 NCCI

87535 81400 NCCI

87535 81401 NCCI

87535 81402 NCCI

87535 81403 NCCI

87535 81404 NCCI

87535 81405 NCCI

87535 81406 NCCI

87535 81407 NCCI

87535 81408 NCCI

87535 87536 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 238 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87536 80500 NCCI

87536 80502 NCCI

87536 81400 NCCI

87536 81401 NCCI

87536 81402 NCCI

87536 81403 NCCI

87536 81404 NCCI

87536 81405 NCCI

87536 81406 NCCI

87536 81407 NCCI

87536 81408 NCCI

87536 87389 NCCI

87536 87390 NCCI

87537 80500 NCCI

87537 80502 NCCI

87537 81400 NCCI

87537 81401 NCCI

87537 81402 NCCI

87537 81403 NCCI

87537 81404 NCCI

87537 81405 NCCI

87537 81406 NCCI

87537 81407 NCCI

87537 81408 NCCI

87537 87538 NCCI

87537 87539 NCCI

87538 80500 NCCI

87538 80502 NCCI

87538 81400 NCCI

87538 81401 NCCI

87538 81402 NCCI

87538 81403 NCCI

87538 81404 NCCI

87538 81405 NCCI

87538 81406 NCCI

87538 81407 NCCI

87538 81408 NCCI

87538 87539 NCCI

87539 80500 NCCI

87539 80502 NCCI

87539 81400 NCCI

87539 81401 NCCI

87539 81402 NCCI

87539 81403 NCCI

87539 81404 NCCI

87539 81405 NCCI

87539 81406 NCCI

Comprehensive ComponentCode Code Source

87539 81407 NCCI

87539 81408 NCCI

87540 80500 NCCI

87540 80502 NCCI

87540 81400 NCCI

87540 81401 NCCI

87540 81402 NCCI

87540 81403 NCCI

87540 81404 NCCI

87540 81405 NCCI

87540 81406 NCCI

87540 81407 NCCI

87540 81408 NCCI

87540 87541 NCCI

87540 87542 NCCI

87541 80500 NCCI

87541 80502 NCCI

87541 81400 NCCI

87541 81401 NCCI

87541 81402 NCCI

87541 81403 NCCI

87541 81404 NCCI

87541 81405 NCCI

87541 81406 NCCI

87541 81407 NCCI

87541 81408 NCCI

87541 87542 NCCI

87542 80500 NCCI

87542 80502 NCCI

87542 81400 NCCI

87542 81401 NCCI

87542 81402 NCCI

87542 81403 NCCI

87542 81404 NCCI

87542 81405 NCCI

87542 81406 NCCI

87542 81407 NCCI

87542 81408 NCCI

87550 80500 NCCI

87550 80502 NCCI

87550 81400 NCCI

87550 81401 NCCI

87550 81402 NCCI

87550 81403 NCCI

87550 81404 NCCI

87550 81405 NCCI

87550 81406 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 239 of 255

Page 240: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87550 81407 NCCI

87550 81408 NCCI

87550 87551 NCCI

87550 87552 NCCI

87551 80500 NCCI

87551 80502 NCCI

87551 81400 NCCI

87551 81401 NCCI

87551 81402 NCCI

87551 81403 NCCI

87551 81404 NCCI

87551 81405 NCCI

87551 81406 NCCI

87551 81407 NCCI

87551 81408 NCCI

87551 87552 NCCI

87552 80500 NCCI

87552 80502 NCCI

87552 81400 NCCI

87552 81401 NCCI

87552 81402 NCCI

87552 81403 NCCI

87552 81404 NCCI

87552 81405 NCCI

87552 81406 NCCI

87552 81407 NCCI

87552 81408 NCCI

87555 80500 NCCI

87555 80502 NCCI

87555 81400 NCCI

87555 81401 NCCI

87555 81402 NCCI

87555 81403 NCCI

87555 81404 NCCI

87555 81405 NCCI

87555 81406 NCCI

87555 81407 NCCI

87555 81408 NCCI

87555 87206 NCCI

87555 87556 NCCI

87555 87557 NCCI

87556 80500 NCCI

87556 80502 NCCI

87556 81400 NCCI

87556 81401 NCCI

87556 81402 NCCI

87556 81403 NCCI

Comprehensive ComponentCode Code Source

87556 81404 NCCI

87556 81405 NCCI

87556 81406 NCCI

87556 81407 NCCI

87556 81408 NCCI

87556 87557 NCCI

87557 80500 NCCI

87557 80502 NCCI

87557 81400 NCCI

87557 81401 NCCI

87557 81402 NCCI

87557 81403 NCCI

87557 81404 NCCI

87557 81405 NCCI

87557 81406 NCCI

87557 81407 NCCI

87557 81408 NCCI

87560 80500 NCCI

87560 80502 NCCI

87560 81400 NCCI

87560 81401 NCCI

87560 81402 NCCI

87560 81403 NCCI

87560 81404 NCCI

87560 81405 NCCI

87560 81406 NCCI

87560 81407 NCCI

87560 81408 NCCI

87560 87206 NCCI

87560 87561 NCCI

87560 87562 NCCI

87561 80500 NCCI

87561 80502 NCCI

87561 81400 NCCI

87561 81401 NCCI

87561 81402 NCCI

87561 81403 NCCI

87561 81404 NCCI

87561 81405 NCCI

87561 81406 NCCI

87561 81407 NCCI

87561 81408 NCCI

87561 87562 NCCI

87562 80500 NCCI

87562 80502 NCCI

87562 81400 NCCI

87562 81401 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 240 of 255

Page 241: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87562 81402 NCCI

87562 81403 NCCI

87562 81404 NCCI

87562 81405 NCCI

87562 81406 NCCI

87562 81407 NCCI

87562 81408 NCCI

87580 80500 NCCI

87580 80502 NCCI

87580 81400 NCCI

87580 81401 NCCI

87580 81402 NCCI

87580 81403 NCCI

87580 81404 NCCI

87580 81405 NCCI

87580 81406 NCCI

87580 81407 NCCI

87580 81408 NCCI

87580 87581 NCCI

87580 87582 NCCI

87581 80500 NCCI

87581 80502 NCCI

87581 81400 NCCI

87581 81401 NCCI

87581 81402 NCCI

87581 81403 NCCI

87581 81404 NCCI

87581 81405 NCCI

87581 81406 NCCI

87581 81407 NCCI

87581 81408 NCCI

87581 87582 NCCI

87582 80500 NCCI

87582 80502 NCCI

87582 81400 NCCI

87582 81401 NCCI

87582 81402 NCCI

87582 81403 NCCI

87582 81404 NCCI

87582 81405 NCCI

87582 81406 NCCI

87582 81407 NCCI

87582 81408 NCCI

87590 80500 NCCI

87590 80502 NCCI

87590 81400 NCCI

87590 81401 NCCI

Comprehensive ComponentCode Code Source

87590 81402 NCCI

87590 81403 NCCI

87590 81404 NCCI

87590 81405 NCCI

87590 81406 NCCI

87590 81407 NCCI

87590 81408 NCCI

87590 87206 NCCI

87590 87449 NCCI

87590 87591 NCCI

87590 87592 NCCI

87591 80500 NCCI

87591 80502 NCCI

87591 81400 NCCI

87591 81401 NCCI

87591 81402 NCCI

87591 81403 NCCI

87591 81404 NCCI

87591 81405 NCCI

87591 81406 NCCI

87591 81407 NCCI

87591 81408 NCCI

87591 87592 NCCI

87592 80500 NCCI

87592 80502 NCCI

87592 81400 NCCI

87592 81401 NCCI

87592 81402 NCCI

87592 81403 NCCI

87592 81404 NCCI

87592 81405 NCCI

87592 81406 NCCI

87592 81407 NCCI

87592 81408 NCCI

87623 80500 NCCI

87623 80502 NCCI

87623 81400 NCCI

87623 81401 NCCI

87623 81402 NCCI

87623 81403 NCCI

87623 81404 NCCI

87623 81405 NCCI

87623 81406 NCCI

87623 81407 NCCI

87623 81408 NCCI

87623 87149 NCCI

87623 87150 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 241 of 255

Page 242: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87623 87153 NCCI

87624 80500 NCCI

87624 80502 NCCI

87624 81400 NCCI

87624 81401 NCCI

87624 81402 NCCI

87624 81403 NCCI

87624 81404 NCCI

87624 81405 NCCI

87624 81406 NCCI

87624 81407 NCCI

87624 81408 NCCI

87624 87149 NCCI

87624 87150 NCCI

87624 87153 NCCI

87624 87623 NCCI

87624 87625 NCCI

87624 G0476 NCCI

87625 80500 NCCI

87625 80502 NCCI

87625 81400 NCCI

87625 81401 NCCI

87625 81402 NCCI

87625 81403 NCCI

87625 81404 NCCI

87625 81405 NCCI

87625 81406 NCCI

87625 81407 NCCI

87625 81408 NCCI

87625 87149 NCCI

87625 87150 NCCI

87625 87153 NCCI

87631 87260 NCCI

87631 87275 NCCI

87631 87276 NCCI

87631 87279 NCCI

87631 87280 NCCI

87631 87301 NCCI

87631 87400 NCCI

87631 87420 NCCI

87631 87501 NCCI

87631 87502 NCCI

87631 87503 NCCI

87631 87801 NCCI

87631 87804 NCCI

87631 87807 NCCI

87631 87809 NCCI

Comprehensive ComponentCode Code Source

87632 87260 NCCI

87632 87275 NCCI

87632 87276 NCCI

87632 87279 NCCI

87632 87280 NCCI

87632 87301 NCCI

87632 87400 NCCI

87632 87420 NCCI

87632 87501 NCCI

87632 87502 NCCI

87632 87503 NCCI

87632 87631 NCCI

87632 87801 NCCI

87632 87804 NCCI

87632 87807 NCCI

87632 87809 NCCI

87633 87260 NCCI

87633 87275 NCCI

87633 87276 NCCI

87633 87279 NCCI

87633 87280 NCCI

87633 87301 NCCI

87633 87400 NCCI

87633 87420 NCCI

87633 87501 NCCI

87633 87502 NCCI

87633 87503 NCCI

87633 87631 NCCI

87633 87632 NCCI

87633 87801 NCCI

87633 87804 NCCI

87633 87807 NCCI

87633 87809 NCCI

87640 80500 NCCI

87640 80502 NCCI

87640 81400 NCCI

87640 81401 NCCI

87640 81402 NCCI

87640 81403 NCCI

87640 81404 NCCI

87640 81405 NCCI

87640 81406 NCCI

87640 81407 NCCI

87640 81408 NCCI

87641 80500 NCCI

87641 80502 NCCI

87641 81400 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 242 of 255

Page 243: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87641 81401 NCCI

87641 81402 NCCI

87641 81403 NCCI

87641 81404 NCCI

87641 81405 NCCI

87641 81406 NCCI

87641 81407 NCCI

87641 81408 NCCI

87641 87640 NCCI

87650 80500 NCCI

87650 80502 NCCI

87650 81400 NCCI

87650 81401 NCCI

87650 81402 NCCI

87650 81403 NCCI

87650 81404 NCCI

87650 81405 NCCI

87650 81406 NCCI

87650 81407 NCCI

87650 81408 NCCI

87650 87651 NCCI

87650 87652 NCCI

87651 80500 NCCI

87651 80502 NCCI

87651 81400 NCCI

87651 81401 NCCI

87651 81402 NCCI

87651 81403 NCCI

87651 81404 NCCI

87651 81405 NCCI

87651 81406 NCCI

87651 81407 NCCI

87651 81408 NCCI

87651 87652 NCCI

87652 80500 NCCI

87652 80502 NCCI

87652 81400 NCCI

87652 81401 NCCI

87652 81402 NCCI

87652 81403 NCCI

87652 81404 NCCI

87652 81405 NCCI

87652 81406 NCCI

87652 81407 NCCI

87652 81408 NCCI

87653 80500 NCCI

87653 80502 NCCI

Comprehensive ComponentCode Code Source

87653 81400 NCCI

87653 81401 NCCI

87653 81402 NCCI

87653 81403 NCCI

87653 81404 NCCI

87653 81405 NCCI

87653 81406 NCCI

87653 81407 NCCI

87653 81408 NCCI

87660 80500 NCCI

87660 80502 NCCI

87660 81400 NCCI

87660 81401 NCCI

87660 81402 NCCI

87660 81403 NCCI

87660 81404 NCCI

87660 81405 NCCI

87660 81406 NCCI

87660 81407 NCCI

87660 81408 NCCI

87660 87177 NCCI

87660 87210 NCCI

87660 87808 NCCI

87661 80500 NCCI

87661 80502 NCCI

87661 81400 NCCI

87661 81401 NCCI

87661 81402 NCCI

87661 81403 NCCI

87661 81404 NCCI

87661 81405 NCCI

87661 81406 NCCI

87661 81407 NCCI

87661 81408 NCCI

87661 87177 NCCI

87661 87210 NCCI

87661 87660 NCCI

87661 87808 NCCI

87797 80500 NCCI

87797 80502 NCCI

87797 81400 NCCI

87797 81401 NCCI

87797 81402 NCCI

87797 81403 NCCI

87797 81404 NCCI

87797 81405 NCCI

87797 81406 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 243 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87797 81407 NCCI

87797 81408 NCCI

87797 87206 NCCI

87797 87449 NCCI

87797 87798 NCCI

87797 87799 NCCI

87797 87807 NCCI

87798 80500 NCCI

87798 80502 NCCI

87798 81400 NCCI

87798 81401 NCCI

87798 81402 NCCI

87798 81403 NCCI

87798 81404 NCCI

87798 81405 NCCI

87798 81406 NCCI

87798 81407 NCCI

87798 81408 NCCI

87798 87206 NCCI

87798 87449 NCCI

87798 87799 NCCI

87798 87807 NCCI

87799 80500 NCCI

87799 80502 NCCI

87799 81400 NCCI

87799 81401 NCCI

87799 81402 NCCI

87799 81403 NCCI

87799 81404 NCCI

87799 81405 NCCI

87799 81406 NCCI

87799 81407 NCCI

87799 81408 NCCI

87799 87807 NCCI

87800 80500 NCCI

87800 80502 NCCI

87800 81400 NCCI

87800 81401 NCCI

87800 81402 NCCI

87800 81403 NCCI

87800 81404 NCCI

87800 81405 NCCI

87800 81406 NCCI

87800 81407 NCCI

87800 81408 NCCI

87800 87470 NCCI

87800 87475 NCCI

Comprehensive ComponentCode Code Source

87800 87480 NCCI

87800 87485 NCCI

87800 87490 NCCI

87800 87495 NCCI

87800 87510 NCCI

87800 87515 NCCI

87800 87520 NCCI

87800 87525 NCCI

87800 87528 NCCI

87800 87531 NCCI

87800 87534 NCCI

87800 87537 NCCI

87800 87540 NCCI

87800 87550 NCCI

87800 87555 NCCI

87800 87560 NCCI

87800 87580 NCCI

87800 87590 NCCI

87800 87623 NCCI

87800 87624 NCCI

87800 87625 NCCI

87800 87650 NCCI

87800 87660 NCCI

87800 87661 NCCI

87800 87797 NCCI

87800 G0476 NCCI

87801 80500 NCCI

87801 80502 NCCI

87801 81400 NCCI

87801 81401 NCCI

87801 81402 NCCI

87801 81403 NCCI

87801 81404 NCCI

87801 81405 NCCI

87801 81406 NCCI

87801 81407 NCCI

87801 81408 NCCI

87801 87471 NCCI

87801 87476 NCCI

87801 87481 NCCI

87801 87486 NCCI

87801 87491 NCCI

87801 87496 NCCI

87801 87498 NCCI

87801 87511 NCCI

87801 87516 NCCI

87801 87521 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 244 of 255

Page 245: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87801 87526 NCCI

87801 87529 NCCI

87801 87532 NCCI

87801 87535 NCCI

87801 87538 NCCI

87801 87541 NCCI

87801 87551 NCCI

87801 87556 NCCI

87801 87561 NCCI

87801 87581 NCCI

87801 87591 NCCI

87801 87640 NCCI

87801 87641 NCCI

87801 87651 NCCI

87801 87653 NCCI

87801 87798 NCCI

87802 80500 NCCI

87802 80502 NCCI

87802 87653 NCCI

87803 80500 NCCI

87803 80502 NCCI

87804 80500 NCCI

87804 80502 NCCI

87806 86701 NCCI

87806 86702 NCCI

87806 86703 NCCI

87806 87389 NCCI

87806 87390 NCCI

87806 87534 NCCI

87806 87535 NCCI

87806 87536 NCCI

87806 G0475 NCCI

87807 80500 NCCI

87807 80502 NCCI

87807 87280 NCCI

87807 87420 NCCI

87808 80500 NCCI

87808 80502 NCCI

87809 80500 NCCI

87809 80502 NCCI

87810 80500 NCCI

87810 80502 NCCI

87810 87270 NCCI

87810 87320 NCCI

87810 87490 NCCI

87810 87491 NCCI

87810 87492 NCCI

Comprehensive ComponentCode Code Source

87850 80500 NCCI

87850 80502 NCCI

87850 87590 NCCI

87850 87591 NCCI

87850 87592 NCCI

87880 80500 NCCI

87880 80502 NCCI

87880 87650 NCCI

87880 87651 NCCI

87880 87652 NCCI

87899 80500 NCCI

87899 80502 NCCI

87900 80500 NCCI

87900 80502 NCCI

87901 80500 NCCI

87901 80502 NCCI

87901 81400 NCCI

87901 81401 NCCI

87901 81402 NCCI

87901 81403 NCCI

87901 81404 NCCI

87901 81405 NCCI

87901 81406 NCCI

87901 81407 NCCI

87901 81408 NCCI

87902 80500 NCCI

87902 80502 NCCI

87902 81400 NCCI

87902 81401 NCCI

87902 81402 NCCI

87902 81403 NCCI

87902 81404 NCCI

87902 81405 NCCI

87902 81406 NCCI

87902 81407 NCCI

87902 81408 NCCI

87903 80500 NCCI

87903 80502 NCCI

87903 81400 NCCI

87903 81401 NCCI

87903 81402 NCCI

87903 81403 NCCI

87903 81404 NCCI

87903 81405 NCCI

87903 81406 NCCI

87903 81407 NCCI

87903 81408 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 245 of 255

Page 246: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

87903 87900 NCCI

87904 81400 NCCI

87904 81401 NCCI

87904 81402 NCCI

87904 81403 NCCI

87904 81404 NCCI

87904 81405 NCCI

87904 81406 NCCI

87904 81407 NCCI

87904 81408 NCCI

87904 87900 NCCI

87905 82657 NCCI

87905 84275 NCCI

87906 80500 NCCI

87906 80502 NCCI

87912 81400 NCCI

87912 81401 NCCI

87912 81402 NCCI

87912 81403 NCCI

87912 81404 NCCI

87912 81405 NCCI

87912 81406 NCCI

87912 81407 NCCI

87912 81408 NCCI

87999 87999 BCBST

88099 88099 BCBST

88104 88104 BCBST

88104 88106 NCCI

88104 88172 NCCI

88104 88173 NCCI

88104 88387 NCCI

88106 88106 BCBST

88106 88387 NCCI

88108 88104 NCCI

88108 88106 NCCI

88108 88108 BCBST

88108 88387 NCCI

88112 88104 NCCI

88112 88106 NCCI

88112 88108 NCCI

88112 88142 NCCI

88112 88143 NCCI

88112 88160 NCCI

88112 88161 NCCI

88112 88162 NCCI

88112 88174 NCCI

88112 88175 NCCI

Comprehensive ComponentCode Code Source

88112 88387 NCCI

88120 80500 NCCI

88120 80502 NCCI

88120 88121 NCCI

88120 88271 NCCI

88120 88272 NCCI

88120 88273 NCCI

88120 88274 NCCI

88120 88275 NCCI

88120 88358 NCCI

88120 88365 NCCI

88120 88366 NCCI

88120 88368 NCCI

88120 88374 NCCI

88120 88377 NCCI

88120 88380 NCCI

88120 88381 NCCI

88121 80500 NCCI

88121 80502 NCCI

88121 88271 NCCI

88121 88272 NCCI

88121 88273 NCCI

88121 88274 NCCI

88121 88275 NCCI

88121 88358 NCCI

88121 88365 NCCI

88121 88366 NCCI

88121 88367 NCCI

88121 88368 NCCI

88121 88374 NCCI

88121 88377 NCCI

88121 88380 NCCI

88121 88381 NCCI

88125 88125 BCBST

88125 88387 NCCI

88130 88387 NCCI

88140 88387 NCCI

88141 88141 BCBST

88141 88387 NCCI

88141 G0123 NCCI

88141 G0124 NCCI

88141 G0141 NCCI

88141 G0143 NCCI

88141 G0144 NCCI

88141 G0145 NCCI

88141 G0147 NCCI

88141 G0148 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 246 of 255

Page 247: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

88141 P3000 NCCI

88142 88108 NCCI

88142 88142 BCBST

88142 88147 NCCI

88142 88148 NCCI

88142 88150 NCCI

88142 88152 NCCI

88142 88153 NCCI

88142 88154 NCCI

88142 88164 NCCI

88142 88165 NCCI

88142 88166 NCCI

88142 88167 NCCI

88142 88387 NCCI

88142 G0123 NCCI

88142 G0143 NCCI

88142 G0147 NCCI

88142 G0148 NCCI

88142 P3000 NCCI

88143 88142 NCCI

88143 88143 BCBST

88143 88147 NCCI

88143 88148 NCCI

88143 88150 NCCI

88143 88152 NCCI

88143 88153 NCCI

88143 88154 NCCI

88143 88164 NCCI

88143 88165 NCCI

88143 88166 NCCI

88143 88167 NCCI

88143 88387 NCCI

88143 G0123 NCCI

88143 G0143 NCCI

88143 G0147 NCCI

88143 G0148 NCCI

88143 P3000 NCCI

88147 88147 BCBST

88147 88150 NCCI

88147 88164 NCCI

88147 88387 NCCI

88147 G0123 NCCI

88147 G0143 NCCI

88147 G0144 NCCI

88147 G0145 NCCI

88147 G0147 NCCI

88147 G0148 NCCI

Comprehensive ComponentCode Code Source

88147 P3000 NCCI

88148 88147 NCCI

88148 88148 BCBST

88148 88150 NCCI

88148 88153 NCCI

88148 88164 NCCI

88148 88165 NCCI

88148 88387 NCCI

88148 G0123 NCCI

88148 G0143 NCCI

88148 G0144 NCCI

88148 G0145 NCCI

88148 G0147 NCCI

88148 G0148 NCCI

88148 P3000 NCCI

88150 88104 NCCI

88150 88106 NCCI

88150 88108 NCCI

88150 88150 BCBST

88150 88160 NCCI

88150 88161 NCCI

88150 88162 NCCI

88150 88174 Reversed NCCI

88150 88175 Reversed NCCI

88150 88387 NCCI

88150 G0123 NCCI

88150 G0143 NCCI

88150 G0144 NCCI

88150 G0145 NCCI

88150 G0147 NCCI

88150 G0148 NCCI

88150 P3000 NCCI

88152 88108 NCCI

88152 88147 NCCI

88152 88148 NCCI

88152 88150 NCCI

88152 88152 BCBST

88152 88153 NCCI

88152 88164 NCCI

88152 88165 NCCI

88152 88174 Reversed NCCI

88152 88175 Reversed NCCI

88152 88387 NCCI

88152 G0123 NCCI

88152 G0143 NCCI

88152 G0144 NCCI

88152 G0145 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 247 of 255

Page 248: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

88152 G0147 NCCI

88152 G0148 NCCI

88152 P3000 NCCI

88153 88147 NCCI

88153 88150 NCCI

88153 88153 BCBST

88153 88164 NCCI

88153 88174 Reversed NCCI

88153 88175 Reversed NCCI

88153 88387 NCCI

88153 G0123 NCCI

88153 G0143 NCCI

88153 G0144 NCCI

88153 G0145 NCCI

88153 G0147 NCCI

88153 G0148 NCCI

88153 P3000 NCCI

88154 88147 NCCI

88154 88148 NCCI

88154 88150 NCCI

88154 88152 NCCI

88154 88153 NCCI

88154 88154 BCBST

88154 88164 NCCI

88154 88165 NCCI

88154 88166 NCCI

88154 88174 Reversed NCCI

88154 88175 Reversed NCCI

88154 88387 NCCI

88154 G0123 NCCI

88154 G0143 NCCI

88154 G0144 NCCI

88154 G0145 NCCI

88154 G0147 NCCI

88154 G0148 NCCI

88154 P3000 NCCI

88155 88104 NCCI

88155 88106 NCCI

88155 88108 NCCI

88155 88387 NCCI

88160 88104 NCCI

88160 88106 NCCI

88160 88108 NCCI

88160 88160 BCBST

88160 88173 NCCI

88160 88387 NCCI

88161 88104 NCCI

Comprehensive ComponentCode Code Source

88161 88106 NCCI

88161 88108 NCCI

88161 88160 NCCI

88161 88161 BCBST

88161 88387 NCCI

88162 88104 NCCI

88162 88106 NCCI

88162 88108 NCCI

88162 88160 NCCI

88162 88161 NCCI

88162 88162 BCBST

88162 88173 NCCI

88162 88334 NCCI

88162 88387 NCCI

88164 88104 NCCI

88164 88106 NCCI

88164 88108 NCCI

88164 88150 NCCI

88164 88160 NCCI

88164 88161 NCCI

88164 88162 NCCI

88164 88164 BCBST

88164 88174 Reversed NCCI

88164 88175 Reversed NCCI

88164 88387 NCCI

88164 G0123 NCCI

88164 G0143 NCCI

88164 G0144 NCCI

88164 G0145 NCCI

88164 G0147 NCCI

88164 G0148 NCCI

88164 P3000 NCCI

88165 88147 NCCI

88165 88150 NCCI

88165 88153 NCCI

88165 88164 NCCI

88165 88165 BCBST

88165 88174 Reversed NCCI

88165 88175 Reversed NCCI

88165 88387 NCCI

88165 G0123 NCCI

88165 G0143 NCCI

88165 G0144 NCCI

88165 G0145 NCCI

88165 G0147 NCCI

88165 G0148 NCCI

88165 P3000 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 248 of 255

Page 249: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

88166 88108 NCCI

88166 88147 NCCI

88166 88148 NCCI

88166 88150 NCCI

88166 88152 NCCI

88166 88153 NCCI

88166 88164 NCCI

88166 88165 NCCI

88166 88166 BCBST

88166 88174 Reversed NCCI

88166 88175 Reversed NCCI

88166 88387 NCCI

88166 G0123 NCCI

88166 G0143 NCCI

88166 G0144 NCCI

88166 G0145 NCCI

88166 G0147 NCCI

88166 G0148 NCCI

88166 P3000 NCCI

88167 88147 NCCI

88167 88148 NCCI

88167 88150 NCCI

88167 88152 NCCI

88167 88153 NCCI

88167 88154 NCCI

88167 88164 NCCI

88167 88165 NCCI

88167 88166 NCCI

88167 88167 BCBST

88167 88174 Reversed NCCI

88167 88175 Reversed NCCI

88167 88387 NCCI

88167 G0123 NCCI

88167 G0143 NCCI

88167 G0144 NCCI

88167 G0145 NCCI

88167 G0147 NCCI

88167 G0148 NCCI

88167 P3000 NCCI

88172 88162 NCCI

88172 88329 NCCI

88172 88334 NCCI

88172 88387 NCCI

88172 88388 NCCI

88173 88108 NCCI

88173 88112 NCCI

88173 88329 NCCI

Comprehensive ComponentCode Code Source

88173 88333 NCCI

88173 88334 NCCI

88173 88387 NCCI

88174 88108 NCCI

88174 88142 NCCI

88174 88143 NCCI

88174 88147 NCCI

88174 88148 NCCI

88174 88174 BCBST

88174 88387 NCCI

88174 G0123 NCCI

88174 G0143 NCCI

88174 G0144 NCCI

88174 G0145 NCCI

88174 G0147 NCCI

88174 G0148 NCCI

88174 P3000 NCCI

88175 88108 NCCI

88175 88142 NCCI

88175 88143 NCCI

88175 88147 NCCI

88175 88148 NCCI

88175 88174 NCCI

88175 88175 BCBST

88175 88387 NCCI

88175 G0123 NCCI

88175 G0143 NCCI

88175 G0144 NCCI

88175 G0145 NCCI

88175 G0147 NCCI

88175 G0148 NCCI

88175 P3000 NCCI

88182 86355 NCCI

88182 86356 NCCI

88182 86357 NCCI

88182 86361 NCCI

88182 86367 NCCI

88182 88387 NCCI

88182 88388 NCCI

88184 86355 NCCI

88184 86356 NCCI

88184 86357 NCCI

88184 86359 NCCI

88184 86360 NCCI

88184 86361 NCCI

88184 86367 NCCI

88184 88108 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 249 of 255

Page 250: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

88184 88112 NCCI

88184 88160 NCCI

88184 88161 NCCI

88184 88162 NCCI

88184 88342 NCCI

88184 88344 NCCI

88184 88387 NCCI

88184 88388 NCCI

88185 88387 NCCI

88185 88388 NCCI

88187 86355 NCCI

88187 86356 NCCI

88187 86357 NCCI

88187 86359 NCCI

88187 86360 NCCI

88187 86361 NCCI

88187 86367 NCCI

88187 88108 NCCI

88187 88112 NCCI

88187 88160 NCCI

88187 88161 NCCI

88187 88162 NCCI

88187 88342 NCCI

88187 88344 NCCI

88187 88387 NCCI

88187 88388 NCCI

88188 86355 NCCI

88188 86356 NCCI

88188 86357 NCCI

88188 86359 NCCI

88188 86360 NCCI

88188 86361 NCCI

88188 86367 NCCI

88188 88108 NCCI

88188 88112 NCCI

88188 88160 NCCI

88188 88161 NCCI

88188 88162 NCCI

88188 88187 NCCI

88188 88342 NCCI

88188 88344 NCCI

88188 88387 NCCI

88188 88388 NCCI

88189 86355 NCCI

88189 86356 NCCI

88189 86357 NCCI

88189 86359 NCCI

Comprehensive ComponentCode Code Source

88189 86360 NCCI

88189 86361 NCCI

88189 86367 NCCI

88189 88108 NCCI

88189 88112 NCCI

88189 88160 NCCI

88189 88161 NCCI

88189 88162 NCCI

88189 88187 NCCI

88189 88188 NCCI

88189 88342 NCCI

88189 88344 NCCI

88189 88387 NCCI

88189 88388 NCCI

88199 88199 BCBST

88240 0058T NCCI

88240 86930 NCCI

88240 89258 NCCI

88240 89259 NCCI

88241 86931 NCCI

88245 80500 NCCI

88245 80502 NCCI

88245 88245 BCBST

88248 80500 NCCI

88248 80502 NCCI

88248 88245 NCCI

88248 88248 BCBST

88249 80500 NCCI

88249 80502 NCCI

88261 80500 NCCI

88261 80502 NCCI

88261 88261 BCBST

88262 80500 NCCI

88262 80502 NCCI

88262 88261 NCCI

88262 88262 BCBST

88263 80500 NCCI

88263 80502 NCCI

88263 88261 NCCI

88263 88262 NCCI

88263 88263 BCBST

88264 80500 NCCI

88264 80502 NCCI

88264 88261 NCCI

88264 88262 NCCI

88264 88264 BCBST

88267 80500 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 250 of 255

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Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

88267 80502 NCCI

88267 88267 BCBST

88269 80500 NCCI

88269 80502 NCCI

88269 88267 NCCI

88271 80500 NCCI

88271 80502 NCCI

88272 80500 NCCI

88272 80502 NCCI

88273 80500 NCCI

88273 80502 NCCI

88273 88272 NCCI

88274 80500 NCCI

88274 80502 NCCI

88275 80500 NCCI

88275 80502 NCCI

88275 88274 NCCI

88280 80500 NCCI

88280 80502 NCCI

88283 80500 NCCI

88283 80502 NCCI

88283 88283 BCBST

88285 80500 NCCI

88285 80502 NCCI

88289 80500 NCCI

88289 80502 NCCI

88289 88289 BCBST

88291 80500 NCCI

88291 80502 NCCI

88299 88299 BCBST

88302 88387 NCCI

88302 89060 NCCI

88304 88160 NCCI

88304 88161 NCCI

88304 88162 NCCI

88304 88387 NCCI

88304 89060 NCCI

88305 88160 NCCI

88305 88161 NCCI

88305 88162 NCCI

88305 88387 NCCI

88305 89060 NCCI

88307 88160 NCCI

88307 88161 NCCI

88307 88162 NCCI

88307 88387 NCCI

88307 89060 NCCI

Comprehensive ComponentCode Code Source

88309 88160 NCCI

88309 88161 NCCI

88309 88162 NCCI

88309 88387 NCCI

88309 89060 NCCI

88313 85536 NCCI

88313 88358 NCCI

88314 88314 BCBST

88319 83876 NCCI

88321 85097 NCCI

88321 87209 NCCI

88321 88104 NCCI

88321 88106 NCCI

88321 88108 NCCI

88321 88120 NCCI

88321 88121 NCCI

88321 88125 NCCI

88321 88130 NCCI

88321 88140 NCCI

88321 88141 NCCI

88321 88160 NCCI

88321 88161 NCCI

88321 88162 NCCI

88321 88173 NCCI

88321 88182 NCCI

88321 88184 NCCI

88321 88187 NCCI

88321 88188 NCCI

88321 88189 NCCI

88321 88302 NCCI

88321 88304 NCCI

88321 88305 NCCI

88321 88307 NCCI

88321 88309 NCCI

88321 88312 NCCI

88321 88313 NCCI

88321 88314 NCCI

88321 88319 NCCI

88321 88342 NCCI

88321 88344 NCCI

88321 88346 NCCI

88321 88348 NCCI

88321 88355 NCCI

88321 88356 NCCI

88321 88358 NCCI

88321 88360 NCCI

88321 88361 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 251 of 255

Page 252: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

88321 88363 NCCI

88321 88365 NCCI

88321 88366 NCCI

88321 88367 NCCI

88321 88368 NCCI

88321 88371 NCCI

88321 88372 NCCI

88321 88374 NCCI

88321 88377 NCCI

88321 88387 NCCI

88321 88388 NCCI

88323 85097 NCCI

88323 87209 NCCI

88323 88104 NCCI

88323 88106 NCCI

88323 88108 NCCI

88323 88120 NCCI

88323 88121 NCCI

88323 88125 NCCI

88323 88130 NCCI

88323 88140 NCCI

88323 88141 NCCI

88323 88160 NCCI

88323 88161 NCCI

88323 88162 NCCI

88323 88173 NCCI

88323 88182 NCCI

88323 88184 NCCI

88323 88187 NCCI

88323 88188 NCCI

88323 88189 NCCI

88323 88302 NCCI

88323 88304 NCCI

88323 88305 NCCI

88323 88307 NCCI

88323 88309 NCCI

88323 88312 NCCI

88323 88313 NCCI

88323 88314 NCCI

88323 88319 NCCI

88323 88321 NCCI

88323 88323 BCBST

88323 88342 NCCI

88323 88344 NCCI

88323 88346 NCCI

88323 88348 NCCI

88323 88355 NCCI

Comprehensive ComponentCode Code Source

88323 88356 NCCI

88323 88358 NCCI

88323 88360 NCCI

88323 88361 NCCI

88323 88363 NCCI

88323 88365 NCCI

88323 88366 NCCI

88323 88367 NCCI

88323 88368 NCCI

88323 88371 NCCI

88323 88372 NCCI

88323 88374 NCCI

88323 88377 NCCI

88323 88387 NCCI

88323 88388 NCCI

88325 85097 NCCI

88325 87209 NCCI

88325 88104 NCCI

88325 88106 NCCI

88325 88108 NCCI

88325 88120 NCCI

88325 88121 NCCI

88325 88125 NCCI

88325 88130 NCCI

88325 88140 NCCI

88325 88141 NCCI

88325 88160 NCCI

88325 88161 NCCI

88325 88162 NCCI

88325 88173 NCCI

88325 88182 NCCI

88325 88184 NCCI

88325 88187 NCCI

88325 88188 NCCI

88325 88189 NCCI

88325 88302 NCCI

88325 88304 NCCI

88325 88305 NCCI

88325 88307 NCCI

88325 88309 NCCI

88325 88312 NCCI

88325 88313 NCCI

88325 88314 NCCI

88325 88319 NCCI

88325 88321 NCCI

88325 88323 NCCI

88325 88342 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 252 of 255

Page 253: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

88325 88344 NCCI

88325 88346 NCCI

88325 88348 NCCI

88325 88355 NCCI

88325 88356 NCCI

88325 88358 NCCI

88325 88360 NCCI

88325 88361 NCCI

88325 88363 NCCI

88325 88365 NCCI

88325 88366 NCCI

88325 88367 NCCI

88325 88368 NCCI

88325 88371 NCCI

88325 88372 NCCI

88325 88374 NCCI

88325 88377 NCCI

88325 88387 NCCI

88325 88388 NCCI

88329 88162 NCCI

88329 88387 NCCI

88331 88160 NCCI

88331 88161 NCCI

88331 88162 NCCI

88331 88329 NCCI

88331 88333 NCCI

88331 88334 NCCI

88331 88387 NCCI

88332 88160 NCCI

88332 88161 NCCI

88332 88162 NCCI

88332 88329 NCCI

88332 88333 NCCI

88332 88334 NCCI

88332 88387 NCCI

88333 88160 NCCI

88333 88161 NCCI

88333 88162 NCCI

88333 88172 NCCI

88333 88329 NCCI

88333 88387 NCCI

88334 88160 NCCI

88334 88161 NCCI

88334 88329 NCCI

88334 88387 NCCI

88342 88358 NCCI

88344 88342 NCCI

Comprehensive ComponentCode Code Source

88344 88358 NCCI

88346 88373 NCCI

88355 88380 NCCI

88356 88380 NCCI

88356 88381 NCCI

88358 88380 NCCI

88360 88341 NCCI

88360 88342 NCCI

88360 88344 NCCI

88361 88341 NCCI

88361 88342 NCCI

88361 88344 NCCI

88361 88360 NCCI

88362 88362 BCBST

88362 88380 NCCI

88362 88381 NCCI

88364 88346 NCCI

88365 80500 NCCI

88365 80502 NCCI

88365 88271 NCCI

88365 88272 NCCI

88365 88273 NCCI

88365 88274 NCCI

88365 88275 NCCI

88365 88346 NCCI

88365 88358 NCCI

88366 80500 NCCI

88366 80502 NCCI

88366 88271 NCCI

88366 88272 NCCI

88366 88273 NCCI

88366 88274 NCCI

88366 88275 NCCI

88366 88346 NCCI

88366 88358 NCCI

88366 88367 NCCI

88366 88368 NCCI

88366 88374 NCCI

88367 80500 NCCI

88367 80502 NCCI

88367 88120 NCCI

88367 88271 NCCI

88367 88272 NCCI

88367 88273 NCCI

88367 88274 NCCI

88367 88275 NCCI

88367 88346 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 253 of 255

Page 254: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

88367 88358 NCCI

88367 88365 NCCI

88367 88368 NCCI

88367 88380 NCCI

88367 88381 NCCI

88368 80500 NCCI

88368 80502 NCCI

88368 88271 NCCI

88368 88272 NCCI

88368 88273 NCCI

88368 88274 NCCI

88368 88275 NCCI

88368 88346 NCCI

88368 88358 NCCI

88368 88365 NCCI

88368 88380 NCCI

88368 88381 NCCI

88369 88346 NCCI

88371 80500 NCCI

88371 80502 NCCI

88372 80500 NCCI

88372 80502 NCCI

88372 88371 NCCI

88372 88372 BCBST

88374 80500 NCCI

88374 80502 NCCI

88374 88271 NCCI

88374 88272 NCCI

88374 88273 NCCI

88374 88274 NCCI

88374 88275 NCCI

88374 88346 NCCI

88374 88358 NCCI

88374 88365 NCCI

88374 88368 NCCI

88374 88380 NCCI

88374 88381 NCCI

88375 88300 NCCI

88375 88329 NCCI

88377 80500 NCCI

88377 80502 NCCI

88377 88271 NCCI

88377 88272 NCCI

88377 88273 NCCI

88377 88274 NCCI

88377 88275 NCCI

88377 88346 NCCI

Comprehensive ComponentCode Code Source

88377 88358 NCCI

88377 88365 NCCI

88377 88366 NCCI

88377 88367 NCCI

88377 88374 NCCI

88377 88380 NCCI

88377 88381 NCCI

88380 88360 NCCI

88380 88361 NCCI

88380 88363 NCCI

88380 88380 BCBST

88380 88381 NCCI

88381 88355 NCCI

88381 88358 NCCI

88381 88360 NCCI

88381 88361 NCCI

88381 88363 NCCI

88387 88300 NCCI

88387 88388 NCCI

88388 88300 NCCI

88399 88399 BCBST

88720 82247 NCCI

88738 88740 NCCI

88738 88741 NCCI

88741 83045 NCCI

89050 80500 NCCI

89050 80502 NCCI

89050 89050 BCBST

89051 80500 NCCI

89051 80502 NCCI

89051 89050 NCCI

89051 89051 BCBST

89060 80500 NCCI

89060 80502 NCCI

89060 88387 NCCI

89060 88388 NCCI

89060 89060 BCBST

89125 80500 NCCI

89125 80502 NCCI

89160 80500 NCCI

89160 80502 NCCI

89160 89160 BCBST

89190 80500 NCCI

89190 80502 NCCI

89230 80500 NCCI

89230 80502 NCCI

89251 89250 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 254 of 255

Page 255: BlueCross BlueShield of Tennessee Commercial Code Bundling ... · Effective Date of Service: 7/1/2017 BlueCross BlueShield of Tennessee Commercial Code Bundling Rules Comprehensive

Effective Date of Service: 7/1/2017

BlueCross BlueShield of TennesseeCommercial Code Bundling Rules

Comprehensive ComponentCode Code Source

89255 89255 BCBST

89257 80500 NCCI

89257 80502 NCCI

89257 89257 BCBST

89258 89258 BCBST

89260 80500 NCCI

89260 80502 NCCI

89260 89300 NCCI

89260 89310 NCCI

89260 89320 NCCI

89260 89321 NCCI

89260 G0027 NCCI

89261 80500 NCCI

89261 80502 NCCI

89261 89300 NCCI

89261 89310 NCCI

89261 89320 NCCI

89261 89321 NCCI

89261 G0027 NCCI

89264 89257 NCCI

89300 80500 NCCI

89300 80502 NCCI

89300 89310 NCCI

89300 89321 NCCI

89300 G0027 NCCI

89310 80500 NCCI

89310 80502 NCCI

89310 89321 NCCI

89310 G0027 NCCI

89320 80500 NCCI

89320 80502 NCCI

89320 89300 NCCI

89320 89310 NCCI

89320 89321 NCCI

89320 G0027 NCCI

89321 89257 NCCI

89321 89264 NCCI

89322 89300 NCCI

89322 89310 NCCI

89322 89320 NCCI

89322 89321 NCCI

89322 G0027 NCCI

89325 80500 NCCI

89325 80502 NCCI

89329 80500 NCCI

89329 80502 NCCI

89330 80500 NCCI

Comprehensive ComponentCode Code Source

89330 80502 NCCI

89330 89329 NCCI

89331 81015 NCCI

89337 0058T NCCI

89337 88240 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: 5/22/2017 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 255 of 255