70000-79999 - bluecross blueshield of tennessee
TRANSCRIPT
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
70010 36000 NCCI
70010 36406 NCCI
70010 36410 NCCI
70010 76000 NCCI
70010 76001 NCCI
70010 77001 NCCI
70010 77002 NCCI
70010 77003 NCCI
70010 96372 NCCI
70010 96374 NCCI
70010 96375 NCCI
70010 96376 NCCI
70015 36000 NCCI
70015 36011 NCCI
70015 36406 NCCI
70015 36410 NCCI
70015 76000 NCCI
70015 76001 NCCI
70015 77001 NCCI
70015 77002 NCCI
70015 77003 NCCI
70015 96372 NCCI
70015 96374 NCCI
70015 96375 NCCI
70015 96376 NCCI
70110 70100 NCCI
70130 70120 NCCI
70150 70140 NCCI
70170 76000 NCCI
70170 76001 NCCI
70170 77001 NCCI
70170 77002 NCCI
70170 78660 NCCI
70220 70210 NCCI
70260 70250 NCCI
70310 70300 NCCI
70320 70300 NCCI
70320 70310 NCCI
70330 70328 NCCI
70332 76000 NCCI
70332 76001 NCCI
70332 77001 NCCI
70332 77002 NCCI
70336 01922 NCCI
70355 70300 NCCI
70355 70310 NCCI
70355 70320 NCCI
Comprehensive ComponentCode Code Source
70370 70360 NCCI
70370 74210 NCCI
70370 74230 NCCI
70370 76000 NCCI
70370 76001 NCCI
70370 77001 NCCI
70370 92520 NCCI
70371 70370 NCCI
70371 74210 NCCI
70371 74230 NCCI
70371 76000 NCCI
70371 76001 NCCI
70371 77001 NCCI
70373 36000 NCCI
70373 36011 NCCI
70373 36406 NCCI
70373 36410 NCCI
70373 76000 NCCI
70373 76001 NCCI
70373 77001 NCCI
70373 92520 NCCI
70390 76000 NCCI
70390 76001 NCCI
70390 77001 NCCI
70390 77002 NCCI
70450 01922 NCCI
70450 70480 NCCI
70450 70481 NCCI
70450 70482 NCCI
70450 76380 NCCI
70450 76380 BCBST
70460 01922 NCCI
70460 36000 NCCI
70460 36005 NCCI
70460 36011 NCCI
70460 36406 NCCI
70460 36410 NCCI
70460 70450 NCCI
70460 70480 NCCI
70460 70481 NCCI
70460 70482 NCCI
70460 76000 NCCI
70460 76001 NCCI
70460 76380 NCCI
70460 76380 BCBST
70460 76942 NCCI
70460 76998 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 1 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
70460 77001 NCCI
70460 77002 NCCI
70460 96360 NCCI
70460 96365 NCCI
70460 96372 NCCI
70460 96374 NCCI
70460 96375 NCCI
70460 96376 NCCI
70460 J1642 NCCI
70470 01922 NCCI
70470 36000 NCCI
70470 36005 NCCI
70470 36011 NCCI
70470 36406 NCCI
70470 36410 NCCI
70470 70450 NCCI
70470 70460 NCCI
70470 70480 NCCI
70470 70481 NCCI
70470 70482 NCCI
70470 76000 NCCI
70470 76001 NCCI
70470 76380 NCCI
70470 76380 BCBST
70470 76942 NCCI
70470 76998 NCCI
70470 77001 NCCI
70470 77002 NCCI
70470 96360 NCCI
70470 96365 NCCI
70470 96372 NCCI
70470 96374 NCCI
70470 96375 NCCI
70470 96376 NCCI
70470 J1642 NCCI
70480 01922 NCCI
70480 76380 NCCI
70480 76380 BCBST
70481 01922 NCCI
70481 36000 NCCI
70481 36005 NCCI
70481 36011 NCCI
70481 36406 NCCI
70481 36410 NCCI
70481 70480 NCCI
70481 76000 NCCI
70481 76001 NCCI
Comprehensive ComponentCode Code Source
70481 76380 NCCI
70481 76380 BCBST
70481 76942 NCCI
70481 76998 NCCI
70481 77001 NCCI
70481 77002 NCCI
70481 96360 NCCI
70481 96365 NCCI
70481 96372 NCCI
70481 96374 NCCI
70481 96375 NCCI
70481 96376 NCCI
70481 J1642 NCCI
70482 01922 NCCI
70482 36000 NCCI
70482 36005 NCCI
70482 36011 NCCI
70482 36406 NCCI
70482 36410 NCCI
70482 70480 NCCI
70482 70481 NCCI
70482 76000 NCCI
70482 76001 NCCI
70482 76380 BCBST
70482 76380 NCCI
70482 76942 NCCI
70482 76998 NCCI
70482 77001 NCCI
70482 77002 NCCI
70482 96360 NCCI
70482 96365 NCCI
70482 96372 NCCI
70482 96374 NCCI
70482 96375 NCCI
70482 96376 NCCI
70482 J1642 NCCI
70486 01922 NCCI
70486 76380 NCCI
70486 76380 BCBST
70487 01922 NCCI
70487 36000 NCCI
70487 36005 NCCI
70487 36011 NCCI
70487 36406 NCCI
70487 36410 NCCI
70487 70486 NCCI
70487 76000 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 2 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
70487 76001 NCCI
70487 76380 NCCI
70487 76380 BCBST
70487 76942 NCCI
70487 76998 NCCI
70487 77001 NCCI
70487 77002 NCCI
70487 96360 NCCI
70487 96365 NCCI
70487 96372 NCCI
70487 96374 NCCI
70487 96375 NCCI
70487 96376 NCCI
70487 J1642 NCCI
70488 01922 NCCI
70488 36000 NCCI
70488 36005 NCCI
70488 36011 NCCI
70488 36406 NCCI
70488 36410 NCCI
70488 70486 NCCI
70488 70487 NCCI
70488 76000 NCCI
70488 76001 NCCI
70488 76380 NCCI
70488 76380 BCBST
70488 76942 NCCI
70488 76998 NCCI
70488 77001 NCCI
70488 77002 NCCI
70488 96360 NCCI
70488 96365 NCCI
70488 96372 NCCI
70488 96374 NCCI
70488 96375 NCCI
70488 96376 NCCI
70488 J1642 NCCI
70490 01922 NCCI
70490 76380 NCCI
70490 76380 BCBST
70490 78072 NCCI
70491 01922 NCCI
70491 36000 NCCI
70491 36005 NCCI
70491 36011 NCCI
70491 36406 NCCI
70491 36410 NCCI
Comprehensive ComponentCode Code Source
70491 70490 NCCI
70491 76000 NCCI
70491 76001 NCCI
70491 76380 NCCI
70491 76380 BCBST
70491 76942 NCCI
70491 76998 NCCI
70491 77001 NCCI
70491 77002 NCCI
70491 78072 NCCI
70491 96360 NCCI
70491 96365 NCCI
70491 96372 NCCI
70491 96374 NCCI
70491 96375 NCCI
70491 96376 NCCI
70491 J1642 NCCI
70492 01922 NCCI
70492 36000 NCCI
70492 36005 NCCI
70492 36011 NCCI
70492 36406 NCCI
70492 36410 NCCI
70492 70490 NCCI
70492 70491 NCCI
70492 76000 NCCI
70492 76001 NCCI
70492 76380 NCCI
70492 76380 BCBST
70492 76942 NCCI
70492 76998 NCCI
70492 77001 NCCI
70492 77002 NCCI
70492 78072 NCCI
70492 96360 NCCI
70492 96365 NCCI
70492 96372 NCCI
70492 96374 NCCI
70492 96375 NCCI
70492 96376 NCCI
70492 J1642 NCCI
70496 01916 NCCI
70496 01922 NCCI
70496 01924 NCCI
70496 01925 NCCI
70496 01926 NCCI
70496 36000 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 3 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
70496 36005 NCCI
70496 36011 NCCI
70496 36406 NCCI
70496 36410 BCBST
70496 70450 BCBST
70496 70450 NCCI
70496 70460 NCCI
70496 70460 BCBST
70496 70470 BCBST
70496 70470 NCCI
70496 76000 NCCI
70496 76001 NCCI
70496 76376 NCCI
70496 76377 NCCI
70496 76380 NCCI
70496 76942 NCCI
70496 76998 NCCI
70496 77001 NCCI
70496 77002 NCCI
70496 96360 NCCI
70496 96365 NCCI
70496 96372 NCCI
70496 96374 NCCI
70496 96375 NCCI
70496 96376 NCCI
70498 01916 NCCI
70498 01922 NCCI
70498 01924 NCCI
70498 01925 NCCI
70498 01926 NCCI
70498 36000 NCCI
70498 36005 NCCI
70498 36011 NCCI
70498 36406 NCCI
70498 36410 BCBST
70498 70490 BCBST
70498 70490 NCCI
70498 70491 NCCI
70498 70491 BCBST
70498 70492 BCBST
70498 70492 NCCI
70498 76000 NCCI
70498 76001 NCCI
70498 76376 NCCI
70498 76377 NCCI
70498 76380 NCCI
70498 76942 NCCI
Comprehensive ComponentCode Code Source
70498 76998 NCCI
70498 77001 NCCI
70498 77002 NCCI
70498 96360 NCCI
70498 96365 NCCI
70498 96372 NCCI
70498 96374 NCCI
70498 96375 NCCI
70498 96376 NCCI
70540 01922 NCCI
70540 70547 NCCI
70540 70548 NCCI
70540 A9576 BCBST
70540 A9577 BCBST
70540 A9578 BCBST
70540 A9579 BCBST
70540 Q9953 BCBST
70542 01922 BCBST
70542 36000 BCBST
70542 36005 NCCI
70542 36011 BCBST
70542 36406 BCBST
70542 36410 BCBST
70542 70540 NCCI
70542 76000 NCCI
70542 76001 NCCI
70542 76942 NCCI
70542 76998 NCCI
70542 77001 NCCI
70542 77002 NCCI
70542 96360 NCCI
70542 96365 NCCI
70542 96372 NCCI
70542 96374 NCCI
70542 96375 NCCI
70542 96376 NCCI
70542 A9576 BCBST
70542 A9577 BCBST
70542 A9578 BCBST
70542 A9579 BCBST
70542 J1642 NCCI
70542 Q9953 BCBST
70543 01922 BCBST
70543 36000 BCBST
70543 36005 NCCI
70543 36011 BCBST
70543 36406 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: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 4 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
70543 36410 BCBST
70543 70540 BCBST
70543 70542 BCBST
70543 70543 CPT
70543 76000 NCCI
70543 76001 NCCI
70543 76942 NCCI
70543 76998 NCCI
70543 77001 NCCI
70543 77002 NCCI
70543 96360 NCCI
70543 96365 NCCI
70543 96372 NCCI
70543 96374 NCCI
70543 96375 NCCI
70543 96376 NCCI
70543 J1642 NCCI
70544 01916 NCCI
70544 01922 BCBST
70544 01924 NCCI
70544 01925 NCCI
70544 01926 NCCI
70544 36000 BCBST
70544 36406 BCBST
70544 36410 BCBST
70544 76376 NCCI
70544 76377 NCCI
70544 A9576 BCBST
70544 A9577 BCBST
70544 A9578 BCBST
70544 A9579 BCBST
70544 Q9953 BCBST
70545 01916 NCCI
70545 01922 BCBST
70545 01924 NCCI
70545 01925 NCCI
70545 01926 NCCI
70545 36000 BCBST
70545 36005 NCCI
70545 36011 NCCI
70545 36406 BCBST
70545 36410 BCBST
70545 70544 NCCI
70545 76000 NCCI
70545 76001 NCCI
70545 76376 NCCI
70545 76377 NCCI
Comprehensive ComponentCode Code Source
70545 76942 NCCI
70545 76998 NCCI
70545 77001 NCCI
70545 77002 NCCI
70545 96360 NCCI
70545 96365 NCCI
70545 96372 NCCI
70545 96374 NCCI
70545 96375 NCCI
70545 96376 NCCI
70545 A9576 BCBST
70545 A9577 BCBST
70545 A9578 BCBST
70545 A9579 BCBST
70545 J1642 NCCI
70545 Q9953 BCBST
70546 01916 NCCI
70546 01922 BCBST
70546 01924 NCCI
70546 01925 NCCI
70546 01926 NCCI
70546 36000 BCBST
70546 36005 NCCI
70546 36011 NCCI
70546 36406 BCBST
70546 36410 BCBST
70546 70544 BCBST
70546 70545 NCCI
70546 70546 BCBST
70546 70551 BCBST
70546 70551 NCCI
70546 70552 NCCI
70546 70552 BCBST
70546 76000 NCCI
70546 76001 NCCI
70546 76376 NCCI
70546 76377 NCCI
70546 76942 NCCI
70546 76998 NCCI
70546 77001 NCCI
70546 77002 NCCI
70546 96360 NCCI
70546 96365 NCCI
70546 96372 NCCI
70546 96374 NCCI
70546 96375 NCCI
70546 96376 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 5 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
70546 J1642 NCCI
70547 01916 NCCI
70547 01922 BCBST
70547 01924 NCCI
70547 01925 NCCI
70547 01926 NCCI
70547 36000 BCBST
70547 36011 NCCI
70547 36406 BCBST
70547 36410 BCBST
70547 76000 NCCI
70547 76001 NCCI
70547 76376 NCCI
70547 76377 NCCI
70547 76942 NCCI
70547 76998 NCCI
70547 77001 NCCI
70547 77002 NCCI
70547 A9576 BCBST
70547 A9577 BCBST
70547 A9578 BCBST
70547 A9579 BCBST
70547 Q9953 BCBST
70548 01916 NCCI
70548 01922 BCBST
70548 01924 NCCI
70548 01925 NCCI
70548 01926 NCCI
70548 36000 BCBST
70548 36005 NCCI
70548 36011 NCCI
70548 36406 BCBST
70548 36410 BCBST
70548 70547 NCCI
70548 76000 NCCI
70548 76001 NCCI
70548 76376 NCCI
70548 76377 NCCI
70548 76942 NCCI
70548 76998 NCCI
70548 77001 NCCI
70548 77002 NCCI
70548 96360 NCCI
70548 96365 NCCI
70548 96372 NCCI
70548 96374 NCCI
70548 96375 NCCI
Comprehensive ComponentCode Code Source
70548 96376 NCCI
70548 A9576 BCBST
70548 A9577 BCBST
70548 A9578 BCBST
70548 A9579 BCBST
70548 J1642 NCCI
70548 Q9953 BCBST
70549 01916 NCCI
70549 01922 BCBST
70549 01924 NCCI
70549 01925 NCCI
70549 01926 NCCI
70549 36000 BCBST
70549 36005 NCCI
70549 36011 NCCI
70549 36406 BCBST
70549 36410 BCBST
70549 70547 BCBST
70549 70548 NCCI
70549 70549 BCBST
70549 76000 NCCI
70549 76001 NCCI
70549 76376 NCCI
70549 76377 NCCI
70549 76942 NCCI
70549 76998 NCCI
70549 77001 NCCI
70549 77002 NCCI
70549 96360 NCCI
70549 96365 NCCI
70549 96372 NCCI
70549 96374 NCCI
70549 96375 NCCI
70549 96376 NCCI
70549 J1642 NCCI
70551 01922 NCCI
70551 70544 NCCI
70551 70545 NCCI
70551 70555 NCCI
70551 70557 NCCI
70551 A9576 BCBST
70551 A9577 BCBST
70551 A9578 BCBST
70551 A9579 BCBST
70551 Q9953 BCBST
70552 01922 NCCI
70552 36000 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 6 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
70552 36005 NCCI
70552 36011 NCCI
70552 36406 NCCI
70552 36410 NCCI
70552 70544 NCCI
70552 70545 NCCI
70552 70551 NCCI
70552 70554 NCCI
70552 70555 NCCI
70552 76000 NCCI
70552 76001 NCCI
70552 76942 NCCI
70552 76998 NCCI
70552 77001 NCCI
70552 77002 NCCI
70552 96360 NCCI
70552 96365 NCCI
70552 96372 NCCI
70552 96374 NCCI
70552 96375 NCCI
70552 96376 NCCI
70552 A9576 BCBST
70552 A9577 BCBST
70552 A9578 BCBST
70552 A9579 BCBST
70552 J1642 NCCI
70552 Q9953 BCBST
70553 01922 NCCI
70553 36000 NCCI
70553 36005 NCCI
70553 36011 NCCI
70553 36406 NCCI
70553 36410 NCCI
70553 70544 NCCI
70553 70545 NCCI
70553 70546 NCCI
70553 70551 NCCI
70553 70552 NCCI
70553 70554 NCCI
70553 70555 NCCI
70553 76000 NCCI
70553 76001 NCCI
70553 76942 NCCI
70553 76998 NCCI
70553 77001 NCCI
70553 77002 NCCI
70553 96360 NCCI
Comprehensive ComponentCode Code Source
70553 96365 NCCI
70553 96372 NCCI
70553 96374 NCCI
70553 96375 NCCI
70553 96376 NCCI
70553 J1642 NCCI
70554 01922 NCCI
70554 70551 NCCI
70554 70557 NCCI
70554 70558 NCCI
70554 70559 NCCI
70554 96020 NCCI
70555 01922 NCCI
70555 70554 NCCI
70555 70557 NCCI
70555 70558 NCCI
70555 70559 NCCI
70557 01922 NCCI
70557 70544 NCCI
70557 70545 NCCI
70557 70546 NCCI
70557 70552 NCCI
70557 70553 NCCI
70557 77021 NCCI
70557 A9576 BCBST
70557 A9577 BCBST
70557 A9578 BCBST
70557 A9579 BCBST
70557 Q9953 BCBST
70558 01922 NCCI
70558 36000 NCCI
70558 36005 NCCI
70558 36406 NCCI
70558 36410 NCCI
70558 70544 NCCI
70558 70545 NCCI
70558 70546 NCCI
70558 70551 NCCI
70558 70552 NCCI
70558 70553 NCCI
70558 70557 NCCI
70558 76000 NCCI
70558 76001 NCCI
70558 76942 NCCI
70558 77001 NCCI
70558 77002 NCCI
70558 77021 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 7 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
70558 96360 NCCI
70558 96365 NCCI
70558 96372 NCCI
70558 96374 NCCI
70558 96375 NCCI
70558 96376 NCCI
70558 A9576 BCBST
70558 A9577 BCBST
70558 A9578 BCBST
70558 A9579 BCBST
70558 Q9953 BCBST
70559 01922 NCCI
70559 36000 NCCI
70559 36005 NCCI
70559 36406 NCCI
70559 36410 NCCI
70559 70544 NCCI
70559 70545 NCCI
70559 70546 NCCI
70559 70551 NCCI
70559 70552 NCCI
70559 70553 NCCI
70559 70557 NCCI
70559 70558 NCCI
70559 76000 NCCI
70559 76001 NCCI
70559 76942 NCCI
70559 77001 NCCI
70559 77002 NCCI
70559 77021 NCCI
70559 96360 NCCI
70559 96365 NCCI
70559 96372 NCCI
70559 96374 NCCI
70559 96375 NCCI
70559 96376 NCCI
71010 0175T NCCI
71010 71022 NCCI
71010 71023 NCCI
71010 71030 NCCI
71010 71034 NCCI
71015 71010 NCCI
71015 71020 NCCI
71015 71023 NCCI
71020 0175T NCCI
71020 71010 NCCI
71020 71021 NCCI
Comprehensive ComponentCode Code Source
71020 71022 NCCI
71020 71023 NCCI
71020 71030 NCCI
71020 71034 NCCI
71020 71101 NCCI
71020 71111 NCCI
71021 0175T NCCI
71021 71010 NCCI
71021 71022 NCCI
71021 71023 NCCI
71021 71030 NCCI
71021 71034 NCCI
71021 71111 NCCI
71022 0175T NCCI
71022 71023 NCCI
71022 71034 NCCI
71022 71111 NCCI
71023 71034 NCCI
71023 76000 NCCI
71023 76001 NCCI
71023 77001 NCCI
71030 0175T NCCI
71030 71022 NCCI
71030 71023 NCCI
71030 71111 NCCI
71034 71030 NCCI
71034 76000 NCCI
71034 76001 NCCI
71034 77001 NCCI
71100 71010 NCCI
71101 71010 NCCI
71101 71021 NCCI
71101 71022 NCCI
71101 71023 NCCI
71101 71030 NCCI
71101 71034 NCCI
71101 71100 NCCI
71110 71010 NCCI
71110 71100 NCCI
71110 71101 NCCI
71111 71010 NCCI
71111 71100 NCCI
71111 71101 NCCI
71111 71110 NCCI
71250 01922 NCCI
71250 75571 NCCI
71250 76380 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 8 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
71250 76380 BCBST
71260 01922 NCCI
71260 36000 NCCI
71260 36005 NCCI
71260 36011 NCCI
71260 36406 NCCI
71260 36410 NCCI
71260 71250 NCCI
71260 75571 NCCI
71260 76000 NCCI
71260 76001 NCCI
71260 76380 NCCI
71260 76942 NCCI
71260 76998 NCCI
71260 77001 NCCI
71260 77002 NCCI
71260 96360 NCCI
71260 96365 NCCI
71260 96372 NCCI
71260 96374 NCCI
71260 96375 NCCI
71260 96376 NCCI
71260 J1642 NCCI
71270 01922 NCCI
71270 36000 NCCI
71270 36005 NCCI
71270 36011 NCCI
71270 36406 NCCI
71270 36410 NCCI
71270 71250 NCCI
71270 71260 NCCI
71270 75571 NCCI
71270 76000 NCCI
71270 76001 NCCI
71270 76380 NCCI
71270 76380 BCBST
71270 76942 NCCI
71270 76998 NCCI
71270 77001 NCCI
71270 77002 NCCI
71270 96360 NCCI
71270 96365 NCCI
71270 96372 NCCI
71270 96374 NCCI
71270 96375 NCCI
71270 96376 NCCI
71270 J1642 NCCI
Comprehensive ComponentCode Code Source
71275 01916 NCCI
71275 01922 BCBST
71275 01924 NCCI
71275 01925 NCCI
71275 01926 NCCI
71275 36000 BCBST
71275 36005 NCCI
71275 36011 NCCI
71275 36406 BCBST
71275 36410 BCBST
71275 71250 NCCI
71275 71250 BCBST
71275 71260 NCCI
71275 71260 BCBST
71275 71270 BCBST
71275 71270 NCCI
71275 76000 NCCI
71275 76001 NCCI
71275 76376 NCCI
71275 76377 NCCI
71275 76380 NCCI
71275 76380 BCBST
71275 76942 NCCI
71275 76998 NCCI
71275 77001 NCCI
71275 77002 NCCI
71275 96360 NCCI
71275 96365 NCCI
71275 96372 NCCI
71275 96374 NCCI
71275 96375 NCCI
71275 96376 NCCI
71550 01922 NCCI
71550 A9576 BCBST
71550 A9577 BCBST
71550 A9578 BCBST
71550 A9579 BCBST
71550 C8903 BCBST
71550 C8904 BCBST
71550 C8905 BCBST
71550 C8906 BCBST
71550 C8907 BCBST
71550 C8908 BCBST
71550 Q9953 BCBST
71551 01922 BCBST
71551 36000 NCCI
71551 36005 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 9 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
71551 36011 NCCI
71551 36406 NCCI
71551 36410 NCCI
71551 71550 NCCI
71551 76000 NCCI
71551 76001 NCCI
71551 76942 NCCI
71551 76998 NCCI
71551 77001 NCCI
71551 77002 NCCI
71551 96360 NCCI
71551 96365 NCCI
71551 96372 NCCI
71551 96374 NCCI
71551 96375 NCCI
71551 96376 NCCI
71551 A9576 BCBST
71551 A9577 BCBST
71551 A9578 BCBST
71551 A9579 BCBST
71551 C8903 BCBST
71551 C8904 BCBST
71551 C8905 BCBST
71551 C8906 BCBST
71551 C8907 BCBST
71551 C8908 BCBST
71551 J1642 NCCI
71551 Q9953 BCBST
71552 01922 BCBST
71552 36000 NCCI
71552 36005 NCCI
71552 36011 NCCI
71552 36406 NCCI
71552 36410 NCCI
71552 71550 BCBST
71552 71551 NCCI
71552 71552 BCBST
71552 71555 NCCI
71552 76000 NCCI
71552 76001 NCCI
71552 76942 NCCI
71552 76998 NCCI
71552 77001 NCCI
71552 77002 NCCI
71552 96360 NCCI
71552 96365 NCCI
71552 96372 NCCI
Comprehensive ComponentCode Code Source
71552 96374 NCCI
71552 96375 NCCI
71552 96376 NCCI
71552 C8903 BCBST
71552 C8904 BCBST
71552 C8905 BCBST
71552 C8906 BCBST
71552 C8907 BCBST
71552 C8908 BCBST
71552 J1642 NCCI
71555 01916 NCCI
71555 01922 NCCI
71555 01924 NCCI
71555 01925 NCCI
71555 01926 NCCI
71555 36000 NCCI
71555 36005 NCCI
71555 36410 NCCI
71555 71550 NCCI
71555 71550 BCBST
71555 71551 NCCI
71555 76000 NCCI
71555 76001 NCCI
71555 76376 NCCI
71555 76377 NCCI
71555 76942 NCCI
71555 76998 NCCI
71555 77001 NCCI
71555 77002 NCCI
71555 96360 NCCI
71555 96365 NCCI
71555 96372 NCCI
71555 96374 NCCI
71555 96375 NCCI
71555 96376 NCCI
71555 A9576 BCBST
71555 A9577 BCBST
71555 A9578 BCBST
71555 A9579 BCBST
71555 C8909 BCBST
71555 C8910 BCBST
71555 C8911 BCBST
71555 J1642 NCCI
71555 Q9953 BCBST
72010 72020 NCCI
72010 72040 NCCI
72010 72050 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 10 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
72010 72052 NCCI
72010 72069 NCCI
72010 72070 NCCI
72010 72072 NCCI
72010 72074 NCCI
72010 72080 NCCI
72010 72090 NCCI
72010 72100 NCCI
72010 72100 BCBST
72010 72110 NCCI
72010 72114 NCCI
72010 72120 NCCI
72050 72020 NCCI
72050 72040 NCCI
72052 72020 NCCI
72052 72040 NCCI
72052 72050 NCCI
72069 72090 NCCI
72070 72090 Reversed NCCI
72072 72070 NCCI
72072 72090 NCCI
72074 72069 NCCI
72074 72070 NCCI
72074 72072 NCCI
72074 72090 NCCI
72080 72069 NCCI
72080 72070 NCCI
72080 72072 NCCI
72080 72074 NCCI
72090 72080 NCCI
72110 72020 NCCI
72110 72100 NCCI
72110 72114 NCCI
72114 72100 NCCI
72114 72120 NCCI
72120 72110 NCCI
72125 01922 NCCI
72125 76380 NCCI
72125 76380 BCBST
72126 01922 NCCI
72126 36000 NCCI
72126 36005 NCCI
72126 36011 NCCI
72126 36406 NCCI
72126 36410 NCCI
72126 72125 NCCI
72126 76000 NCCI
Comprehensive ComponentCode Code Source
72126 76001 NCCI
72126 76380 NCCI
72126 76380 BCBST
72126 76942 NCCI
72126 76998 NCCI
72126 77001 NCCI
72126 77002 NCCI
72126 96360 NCCI
72126 96365 NCCI
72126 96372 NCCI
72126 96374 NCCI
72126 96375 NCCI
72126 96376 NCCI
72126 J1642 NCCI
72127 01922 NCCI
72127 36000 NCCI
72127 36005 NCCI
72127 36011 NCCI
72127 36406 NCCI
72127 36410 NCCI
72127 72125 NCCI
72127 72126 NCCI
72127 76000 NCCI
72127 76001 NCCI
72127 76380 NCCI
72127 76380 BCBST
72127 76942 NCCI
72127 76998 NCCI
72127 77001 NCCI
72127 77002 NCCI
72127 96360 NCCI
72127 96365 NCCI
72127 96372 NCCI
72127 96374 NCCI
72127 96375 NCCI
72127 96376 NCCI
72127 J1642 NCCI
72128 01922 NCCI
72128 72292 NCCI
72128 76380 NCCI
72128 76380 BCBST
72129 01922 NCCI
72129 36000 NCCI
72129 36005 NCCI
72129 36011 NCCI
72129 36406 NCCI
72129 36410 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 11 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
72129 72128 NCCI
72129 72292 NCCI
72129 76000 NCCI
72129 76001 NCCI
72129 76380 NCCI
72129 76380 BCBST
72129 76942 NCCI
72129 76998 NCCI
72129 77001 NCCI
72129 77002 NCCI
72129 96360 NCCI
72129 96365 NCCI
72129 96372 NCCI
72129 96374 NCCI
72129 96375 NCCI
72129 96376 NCCI
72129 J1642 NCCI
72130 01922 NCCI
72130 36000 NCCI
72130 36005 NCCI
72130 36011 NCCI
72130 36406 NCCI
72130 36410 NCCI
72130 72128 NCCI
72130 72129 NCCI
72130 72292 NCCI
72130 76000 NCCI
72130 76001 NCCI
72130 76380 NCCI
72130 76380 BCBST
72130 76942 NCCI
72130 76998 NCCI
72130 77001 NCCI
72130 77002 NCCI
72130 96360 NCCI
72130 96365 NCCI
72130 96372 NCCI
72130 96374 NCCI
72130 96375 NCCI
72130 96376 NCCI
72130 J1642 NCCI
72131 01922 NCCI
72131 72292 NCCI
72131 76380 NCCI
72131 76380 BCBST
72132 01922 NCCI
72132 36000 NCCI
Comprehensive ComponentCode Code Source
72132 36005 NCCI
72132 36011 NCCI
72132 36406 NCCI
72132 36410 NCCI
72132 72131 NCCI
72132 72292 NCCI
72132 76000 NCCI
72132 76001 NCCI
72132 76380 NCCI
72132 76380 BCBST
72132 76942 NCCI
72132 76998 NCCI
72132 77001 NCCI
72132 77002 NCCI
72132 96360 NCCI
72132 96365 NCCI
72132 96372 NCCI
72132 96374 NCCI
72132 96375 NCCI
72132 96376 NCCI
72132 J1642 NCCI
72133 01922 NCCI
72133 36000 NCCI
72133 36005 NCCI
72133 36011 NCCI
72133 36406 NCCI
72133 36410 NCCI
72133 72131 NCCI
72133 72132 NCCI
72133 72292 NCCI
72133 76000 NCCI
72133 76001 NCCI
72133 76380 NCCI
72133 76380 BCBST
72133 76942 NCCI
72133 76998 NCCI
72133 77001 NCCI
72133 77002 NCCI
72133 96360 NCCI
72133 96365 NCCI
72133 96372 NCCI
72133 96374 NCCI
72133 96375 NCCI
72133 96376 NCCI
72133 J1642 NCCI
72141 01922 NCCI
72141 A9576 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: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 12 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
72141 A9577 BCBST
72141 A9578 BCBST
72141 A9579 BCBST
72141 Q9953 BCBST
72142 01922 NCCI
72142 36000 NCCI
72142 36005 NCCI
72142 36011 NCCI
72142 36406 NCCI
72142 36410 NCCI
72142 72141 NCCI
72142 76000 NCCI
72142 76001 NCCI
72142 76942 NCCI
72142 76998 NCCI
72142 77001 NCCI
72142 77002 NCCI
72142 96360 NCCI
72142 96365 NCCI
72142 96372 NCCI
72142 96374 NCCI
72142 96375 NCCI
72142 96376 NCCI
72142 A9576 BCBST
72142 A9577 BCBST
72142 A9578 BCBST
72142 A9579 BCBST
72142 J1642 NCCI
72142 Q9953 BCBST
72146 01922 NCCI
72146 A9576 BCBST
72146 A9577 BCBST
72146 A9578 BCBST
72146 A9579 BCBST
72146 Q9953 BCBST
72147 01922 NCCI
72147 36000 NCCI
72147 36005 NCCI
72147 36011 NCCI
72147 36406 NCCI
72147 36410 NCCI
72147 72146 NCCI
72147 76000 NCCI
72147 76001 NCCI
72147 76942 NCCI
72147 76998 NCCI
72147 77001 NCCI
Comprehensive ComponentCode Code Source
72147 77002 NCCI
72147 96360 NCCI
72147 96365 NCCI
72147 96372 NCCI
72147 96374 NCCI
72147 96375 NCCI
72147 96376 NCCI
72147 A9576 BCBST
72147 A9577 BCBST
72147 A9578 BCBST
72147 A9579 BCBST
72147 J1642 NCCI
72147 Q9953 BCBST
72148 01922 NCCI
72148 A9576 BCBST
72148 A9577 BCBST
72148 A9578 BCBST
72148 A9579 BCBST
72148 Q9953 BCBST
72149 01922 NCCI
72149 36000 NCCI
72149 36005 NCCI
72149 36011 NCCI
72149 36406 NCCI
72149 36410 NCCI
72149 72148 NCCI
72149 76000 NCCI
72149 76001 NCCI
72149 76942 NCCI
72149 76998 NCCI
72149 77001 NCCI
72149 77002 NCCI
72149 96360 NCCI
72149 96365 NCCI
72149 96372 NCCI
72149 96374 NCCI
72149 96375 NCCI
72149 96376 NCCI
72149 A9576 BCBST
72149 A9577 BCBST
72149 A9578 BCBST
72149 A9579 BCBST
72149 J1642 NCCI
72149 Q9953 BCBST
72156 01922 NCCI
72156 36000 NCCI
72156 36005 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 13 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
72156 36011 NCCI
72156 36406 NCCI
72156 36410 NCCI
72156 72141 NCCI
72156 72142 NCCI
72156 76000 NCCI
72156 76001 NCCI
72156 76942 NCCI
72156 76998 NCCI
72156 77001 NCCI
72156 77002 NCCI
72156 96360 NCCI
72156 96365 NCCI
72156 96372 NCCI
72156 96374 NCCI
72156 96375 NCCI
72156 96376 NCCI
72156 J1642 NCCI
72157 01922 NCCI
72157 36000 NCCI
72157 36005 NCCI
72157 36011 NCCI
72157 36406 NCCI
72157 36410 NCCI
72157 72146 NCCI
72157 72147 NCCI
72157 76000 NCCI
72157 76001 NCCI
72157 76942 NCCI
72157 76998 NCCI
72157 77001 NCCI
72157 77002 NCCI
72157 96360 NCCI
72157 96365 NCCI
72157 96372 NCCI
72157 96374 NCCI
72157 96375 NCCI
72157 96376 NCCI
72157 J1642 NCCI
72158 01922 NCCI
72158 36000 NCCI
72158 36005 NCCI
72158 36011 NCCI
72158 36406 NCCI
72158 36410 NCCI
72158 72148 NCCI
72158 72149 NCCI
Comprehensive ComponentCode Code Source
72158 76000 NCCI
72158 76001 NCCI
72158 76942 NCCI
72158 76998 NCCI
72158 77001 NCCI
72158 77002 NCCI
72158 96360 NCCI
72158 96365 NCCI
72158 96372 NCCI
72158 96374 NCCI
72158 96375 NCCI
72158 96376 NCCI
72158 J1642 NCCI
72159 01916 NCCI
72159 36000 NCCI
72159 36000 NCCI
72159 36005 NCCI
72159 36410 NCCI
72159 72141 NCCI
72159 72142 NCCI
72159 72146 NCCI
72159 72147 NCCI
72159 72148 NCCI
72159 72149 NCCI
72159 72156 NCCI
72159 72157 NCCI
72159 72158 NCCI
72159 76000 NCCI
72159 76001 NCCI
72159 76376 NCCI
72159 76377 NCCI
72159 76942 NCCI
72159 76998 NCCI
72159 77002 NCCI
72159 96360 NCCI
72159 96365 NCCI
72159 96372 NCCI
72159 96374 NCCI
72159 96375 NCCI
72159 96376 NCCI
72159 A9576 BCBST
72159 A9577 BCBST
72159 A9578 BCBST
72159 A9579 BCBST
72159 J1642 NCCI
72159 Q9953 BCBST
72190 72170 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 14 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
72191 01916 NCCI
72191 01922 BCBST
72191 01924 NCCI
72191 01925 NCCI
72191 01926 NCCI
72191 36000 BCBST
72191 36005 NCCI
72191 36011 NCCI
72191 36406 BCBST
72191 36410 BCBST
72191 72192 BCBST
72191 72192 NCCI
72191 72193 NCCI
72191 72193 BCBST
72191 72194 BCBST
72191 72194 NCCI
72191 74176 NCCI
72191 74177 NCCI
72191 74178 NCCI
72191 76000 NCCI
72191 76001 NCCI
72191 76376 NCCI
72191 76377 NCCI
72191 76380 NCCI
72191 76380 BCBST
72191 76942 NCCI
72191 76998 NCCI
72191 77001 NCCI
72191 77002 NCCI
72191 96360 NCCI
72191 96365 NCCI
72191 96372 NCCI
72191 96374 NCCI
72191 96375 NCCI
72191 96376 NCCI
72191 J1642 NCCI
72192 01922 NCCI
72192 76380 NCCI
72192 76380 BCBST
72193 01922 NCCI
72193 36000 NCCI
72193 36005 NCCI
72193 36011 NCCI
72193 36406 NCCI
72193 36410 NCCI
72193 72192 NCCI
72193 76000 NCCI
Comprehensive ComponentCode Code Source
72193 76001 NCCI
72193 76380 NCCI
72193 76380 BCBST
72193 76942 NCCI
72193 76998 NCCI
72193 77001 NCCI
72193 77002 NCCI
72193 96360 NCCI
72193 96365 NCCI
72193 96372 NCCI
72193 96374 NCCI
72193 96375 NCCI
72193 96376 NCCI
72193 J1642 NCCI
72194 01922 NCCI
72194 36000 NCCI
72194 36005 NCCI
72194 36011 NCCI
72194 36406 NCCI
72194 36410 NCCI
72194 72192 NCCI
72194 72193 NCCI
72194 76000 NCCI
72194 76001 NCCI
72194 76380 NCCI
72194 76380 BCBST
72194 76942 NCCI
72194 76998 NCCI
72194 77001 NCCI
72194 77002 NCCI
72194 96360 NCCI
72194 96365 NCCI
72194 96372 NCCI
72194 96374 NCCI
72194 96375 NCCI
72194 96376 NCCI
72194 J1642 NCCI
72195 01922 BCBST
72195 36000 BCBST
72195 36011 BCBST
72195 36406 BCBST
72195 36410 BCBST
72195 A9576 BCBST
72195 A9577 BCBST
72195 A9578 BCBST
72195 A9579 BCBST
72195 Q9953 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: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 15 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
72196 01922 NCCI
72196 36000 NCCI
72196 36005 NCCI
72196 36011 NCCI
72196 36406 NCCI
72196 36410 NCCI
72196 72195 NCCI
72196 76000 NCCI
72196 76001 NCCI
72196 76942 NCCI
72196 76998 NCCI
72196 77001 NCCI
72196 77002 NCCI
72196 96360 NCCI
72196 96365 NCCI
72196 96372 NCCI
72196 96374 NCCI
72196 96375 NCCI
72196 96376 NCCI
72196 A9576 BCBST
72196 A9577 BCBST
72196 A9578 BCBST
72196 A9579 BCBST
72196 J1642 NCCI
72196 Q9953 BCBST
72197 01922 BCBST
72197 36000 BCBST
72197 36005 NCCI
72197 36011 BCBST
72197 36406 BCBST
72197 36410 BCBST
72197 72195 BCBST
72197 72196 NCCI
72197 72197 BCBST
72197 72198 NCCI
72197 76000 NCCI
72197 76001 NCCI
72197 76942 NCCI
72197 76998 NCCI
72197 77001 NCCI
72197 77002 NCCI
72197 96360 NCCI
72197 96365 NCCI
72197 96372 NCCI
72197 96374 NCCI
72197 96375 NCCI
72197 96376 NCCI
Comprehensive ComponentCode Code Source
72197 J1642 NCCI
72198 01916 NCCI
72198 01922 NCCI
72198 01924 NCCI
72198 36000 NCCI
72198 36005 NCCI
72198 36410 NCCI
72198 72195 NCCI
72198 72196 NCCI
72198 72196 BCBST
72198 76000 NCCI
72198 76001 NCCI
72198 76376 NCCI
72198 76377 NCCI
72198 76942 NCCI
72198 76998 NCCI
72198 77001 NCCI
72198 77002 NCCI
72198 96360 NCCI
72198 96365 NCCI
72198 96372 NCCI
72198 96374 NCCI
72198 96375 NCCI
72198 96376 NCCI
72198 A9576 BCBST
72198 A9577 BCBST
72198 A9578 BCBST
72198 A9579 BCBST
72198 J1642 NCCI
72198 Q9953 BCBST
72202 72200 NCCI
72240 00600 NCCI
72240 01935 NCCI
72240 01936 NCCI
72240 20551 NCCI
72240 20552 NCCI
72240 20553 NCCI
72240 72255 NCCI
72240 72265 NCCI
72240 76000 NCCI
72240 76001 NCCI
72240 77001 NCCI
72240 77002 NCCI
72240 77003 NCCI
72255 00620 NCCI
72255 00625 NCCI
72255 00626 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 16 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
72255 01935 NCCI
72255 01936 NCCI
72255 72265 NCCI
72255 76000 NCCI
72255 76001 NCCI
72255 77001 NCCI
72255 77002 NCCI
72255 77003 NCCI
72265 00630 NCCI
72265 01935 NCCI
72265 01936 NCCI
72265 20551 NCCI
72265 20552 NCCI
72265 20553 NCCI
72265 76000 NCCI
72265 76001 NCCI
72265 77001 NCCI
72265 77002 NCCI
72265 77003 NCCI
72270 00600 NCCI
72270 00620 NCCI
72270 00625 NCCI
72270 00626 NCCI
72270 00630 NCCI
72270 01935 NCCI
72270 01936 NCCI
72270 72240 NCCI
72270 72255 NCCI
72270 72265 NCCI
72270 76000 NCCI
72270 76001 NCCI
72270 77001 NCCI
72270 77002 NCCI
72270 77003 NCCI
72275 00600 NCCI
72275 00620 NCCI
72275 00625 NCCI
72275 00626 NCCI
72275 00630 NCCI
72275 01935 NCCI
72275 01936 NCCI
72275 76000 NCCI
72275 76001 NCCI
72275 77001 NCCI
72275 77002 NCCI
72275 77003 NCCI
72285 00600 NCCI
Comprehensive ComponentCode Code Source
72285 00620 NCCI
72285 00625 NCCI
72285 00626 NCCI
72285 01935 NCCI
72285 01936 NCCI
72285 76000 NCCI
72285 76001 NCCI
72285 77001 NCCI
72285 77002 NCCI
72285 77003 NCCI
72291 01935 NCCI
72291 01936 NCCI
72291 75872 NCCI
72291 76000 NCCI
72291 76001 NCCI
72291 77001 NCCI
72291 77002 NCCI
72291 77003 NCCI
72292 01935 NCCI
72292 01936 NCCI
72292 72291 NCCI
72292 75872 NCCI
72292 76380 NCCI
72292 77011 NCCI
72292 77012 NCCI
72295 00630 NCCI
72295 01935 NCCI
72295 01936 NCCI
72295 20551 NCCI
72295 20552 NCCI
72295 20553 NCCI
72295 76000 NCCI
72295 76001 NCCI
72295 77001 NCCI
72295 77002 NCCI
72295 77003 NCCI
73030 73020 NCCI
73040 01922 NCCI
73040 73020 NCCI
73040 73030 NCCI
73040 76000 NCCI
73040 76001 NCCI
73040 77001 NCCI
73040 77002 NCCI
73080 73070 NCCI
73085 01922 NCCI
73085 73070 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 17 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
73085 73080 NCCI
73085 76000 NCCI
73085 76001 NCCI
73085 77001 NCCI
73085 77002 NCCI
73092 73090 NCCI
73110 73100 NCCI
73115 01922 NCCI
73115 73100 NCCI
73115 73110 NCCI
73115 76000 NCCI
73115 76001 NCCI
73115 77001 NCCI
73115 77002 NCCI
73120 73140 NCCI
73130 73120 NCCI
73130 73140 NCCI
73200 01922 NCCI
73200 76380 NCCI
73200 76380 BCBST
73201 01922 NCCI
73201 36000 NCCI
73201 36005 NCCI
73201 36011 NCCI
73201 36406 NCCI
73201 36410 NCCI
73201 73200 NCCI
73201 76000 NCCI
73201 76001 NCCI
73201 76380 NCCI
73201 76380 BCBST
73201 76942 NCCI
73201 76998 NCCI
73201 77001 NCCI
73201 77002 NCCI
73201 96360 NCCI
73201 96365 NCCI
73201 96372 NCCI
73201 96374 NCCI
73201 96375 NCCI
73201 96376 NCCI
73201 J1642 NCCI
73202 01922 NCCI
73202 36000 NCCI
73202 36005 NCCI
73202 36011 NCCI
73202 36406 NCCI
Comprehensive ComponentCode Code Source
73202 36410 NCCI
73202 73200 NCCI
73202 73201 NCCI
73202 76000 NCCI
73202 76001 NCCI
73202 76380 NCCI
73202 76380 BCBST
73202 76942 NCCI
73202 76998 NCCI
73202 77001 NCCI
73202 77002 NCCI
73202 96360 NCCI
73202 96365 NCCI
73202 96372 NCCI
73202 96374 NCCI
73202 96375 NCCI
73202 96376 NCCI
73202 J1642 NCCI
73206 01916 NCCI
73206 01922 BCBST
73206 01924 NCCI
73206 01925 NCCI
73206 01926 NCCI
73206 36000 BCBST
73206 36005 NCCI
73206 36011 NCCI
73206 36406 BCBST
73206 36410 BCBST
73206 73200 BCBST
73206 73200 NCCI
73206 73201 NCCI
73206 73201 BCBST
73206 73202 BCBST
73206 73202 NCCI
73206 76000 NCCI
73206 76001 NCCI
73206 76376 NCCI
73206 76377 NCCI
73206 76380 NCCI
73206 76380 BCBST
73206 76942 NCCI
73206 76998 NCCI
73206 77001 NCCI
73206 77002 NCCI
73206 96360 NCCI
73206 96365 NCCI
73206 96372 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 18 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
73206 96374 NCCI
73206 96375 NCCI
73206 96376 NCCI
73218 01922 BCBST
73218 36000 BCBST
73218 36011 BCBST
73218 36406 BCBST
73218 36410 BCBST
73218 A9576 BCBST
73218 A9577 BCBST
73218 A9578 BCBST
73218 A9579 BCBST
73218 Q9953 BCBST
73219 01922 BCBST
73219 36000 BCBST
73219 36005 NCCI
73219 36011 BCBST
73219 36406 BCBST
73219 36410 BCBST
73219 73218 NCCI
73219 76000 NCCI
73219 76001 NCCI
73219 76942 NCCI
73219 76998 NCCI
73219 77001 NCCI
73219 77002 NCCI
73219 96360 NCCI
73219 96365 NCCI
73219 96372 NCCI
73219 96374 NCCI
73219 96375 NCCI
73219 96376 NCCI
73219 A9576 BCBST
73219 A9577 BCBST
73219 A9578 BCBST
73219 A9579 BCBST
73219 J1642 NCCI
73219 Q9953 BCBST
73220 01922 NCCI
73220 36000 NCCI
73220 36005 NCCI
73220 36011 NCCI
73220 36406 NCCI
73220 36410 NCCI
73220 73218 NCCI
73220 73219 NCCI
73220 76000 NCCI
Comprehensive ComponentCode Code Source
73220 76001 NCCI
73220 76942 NCCI
73220 76998 NCCI
73220 77001 NCCI
73220 77002 NCCI
73220 96360 NCCI
73220 96365 NCCI
73220 96372 NCCI
73220 96374 NCCI
73220 96375 NCCI
73220 96376 NCCI
73220 J1642 NCCI
73221 01922 NCCI
73221 A9576 BCBST
73221 A9577 BCBST
73221 A9578 BCBST
73221 A9579 BCBST
73221 Q9953 BCBST
73222 01922 BCBST
73222 36000 BCBST
73222 36005 NCCI
73222 36011 BCBST
73222 36406 BCBST
73222 36410 BCBST
73222 73221 NCCI
73222 96360 NCCI
73222 96365 NCCI
73222 96372 NCCI
73222 96374 NCCI
73222 96375 NCCI
73222 96376 NCCI
73222 A9576 BCBST
73222 A9577 BCBST
73222 A9578 BCBST
73222 A9579 BCBST
73222 J1642 NCCI
73222 Q9953 BCBST
73223 01922 BCBST
73223 36000 BCBST
73223 36005 NCCI
73223 36011 BCBST
73223 36406 BCBST
73223 36410 BCBST
73223 73221 BCBST
73223 73222 NCCI
73223 73223 BCBST
73223 96360 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 19 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
73223 96365 NCCI
73223 96372 NCCI
73223 96374 NCCI
73223 96375 NCCI
73223 96376 NCCI
73223 J1642 NCCI
73225 01916 NCCI
73225 36000 NCCI
73225 36005 NCCI
73225 36410 NCCI
73225 73218 NCCI
73225 73219 NCCI
73225 73220 NCCI
73225 73221 NCCI
73225 73222 NCCI
73225 73223 NCCI
73225 76000 NCCI
73225 76001 NCCI
73225 76376 NCCI
73225 76377 NCCI
73225 76942 NCCI
73225 76998 NCCI
73225 77002 NCCI
73225 96360 NCCI
73225 96365 NCCI
73225 96372 NCCI
73225 96374 NCCI
73225 96375 NCCI
73225 96376 NCCI
73225 A9576 BCBST
73225 A9577 BCBST
73225 A9578 BCBST
73225 A9579 BCBST
73225 J1642 NCCI
73225 Q9953 BCBST
73510 73500 NCCI
73520 72170 NCCI
73520 73500 NCCI
73520 73510 NCCI
73525 73500 NCCI
73525 73510 NCCI
73525 73520 NCCI
73525 76000 NCCI
73525 76001 NCCI
73525 77001 NCCI
73525 77002 NCCI
73540 72170 NCCI
Comprehensive ComponentCode Code Source
73560 01380 NCCI
73562 01380 NCCI
73562 73560 NCCI
73564 01380 NCCI
73564 73560 NCCI
73564 73562 NCCI
73564 73565 NCCI
73565 01380 NCCI
73565 73562 NCCI
73580 01380 NCCI
73580 01922 NCCI
73580 73560 NCCI
73580 76000 NCCI
73580 76001 NCCI
73580 77001 NCCI
73580 77002 NCCI
73590 73592 NCCI
73592 73610 NCCI
73600 73592 NCCI
73610 73600 NCCI
73615 01922 NCCI
73615 73600 NCCI
73615 73610 NCCI
73615 76000 NCCI
73615 76001 NCCI
73615 77001 NCCI
73615 77002 NCCI
73620 73660 NCCI
73630 73620 NCCI
73700 01922 NCCI
73700 76380 NCCI
73700 76380 BCBST
73701 01922 NCCI
73701 36000 NCCI
73701 36005 NCCI
73701 36011 NCCI
73701 36406 NCCI
73701 36410 NCCI
73701 73700 NCCI
73701 76000 NCCI
73701 76001 NCCI
73701 76380 NCCI
73701 76380 BCBST
73701 76942 NCCI
73701 76998 NCCI
73701 77001 NCCI
73701 77002 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 20 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
73701 96360 NCCI
73701 96365 NCCI
73701 96372 NCCI
73701 96374 NCCI
73701 96375 NCCI
73701 96376 NCCI
73701 J1642 NCCI
73702 01922 NCCI
73702 36000 NCCI
73702 36005 NCCI
73702 36011 NCCI
73702 36406 NCCI
73702 36410 NCCI
73702 73700 NCCI
73702 73701 NCCI
73702 76000 NCCI
73702 76001 NCCI
73702 76380 NCCI
73702 76380 BCBST
73702 76942 NCCI
73702 76998 NCCI
73702 77001 NCCI
73702 77002 NCCI
73702 96360 NCCI
73702 96365 NCCI
73702 96372 NCCI
73702 96374 NCCI
73702 96375 NCCI
73702 96376 NCCI
73702 J1642 NCCI
73706 01916 NCCI
73706 01922 BCBST
73706 01924 NCCI
73706 01925 NCCI
73706 01926 NCCI
73706 36000 BCBST
73706 36005 NCCI
73706 36011 NCCI
73706 36406 BCBST
73706 36410 BCBST
73706 72191 NCCI
73706 73700 NCCI
73706 73700 BCBST
73706 73701 BCBST
73706 73701 NCCI
73706 73702 NCCI
73706 73702 BCBST
Comprehensive ComponentCode Code Source
73706 76000 NCCI
73706 76001 NCCI
73706 76376 NCCI
73706 76377 NCCI
73706 76380 NCCI
73706 76380 BCBST
73706 76942 NCCI
73706 76998 NCCI
73706 77001 NCCI
73706 77002 NCCI
73706 96360 NCCI
73706 96365 NCCI
73706 96372 NCCI
73706 96374 NCCI
73706 96375 NCCI
73706 96376 NCCI
73718 01922 BCBST
73718 36000 BCBST
73718 36011 BCBST
73718 36406 BCBST
73718 36410 BCBST
73718 A9576 BCBST
73718 A9577 BCBST
73718 A9578 BCBST
73718 A9579 BCBST
73718 Q9953 BCBST
73719 01922 BCBST
73719 36000 BCBST
73719 36005 NCCI
73719 36011 BCBST
73719 36406 BCBST
73719 36410 BCBST
73719 73718 NCCI
73719 76000 NCCI
73719 76001 NCCI
73719 76942 NCCI
73719 76998 NCCI
73719 77001 NCCI
73719 77002 NCCI
73719 96360 NCCI
73719 96365 NCCI
73719 96372 NCCI
73719 96374 NCCI
73719 96375 NCCI
73719 96376 NCCI
73719 A9576 BCBST
73719 A9577 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: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 21 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
73719 A9578 BCBST
73719 A9579 BCBST
73719 J1642 NCCI
73719 Q9953 BCBST
73720 01922 NCCI
73720 36000 NCCI
73720 36005 NCCI
73720 36011 NCCI
73720 36406 NCCI
73720 36410 NCCI
73720 73718 NCCI
73720 73719 NCCI
73720 73720 BCBST
73720 73725 NCCI
73720 76000 NCCI
73720 76001 NCCI
73720 76942 NCCI
73720 76998 NCCI
73720 77001 NCCI
73720 77002 NCCI
73720 96360 NCCI
73720 96365 NCCI
73720 96372 NCCI
73720 96374 NCCI
73720 96375 NCCI
73720 96376 NCCI
73720 J1642 NCCI
73721 01922 NCCI
73721 A9576 BCBST
73721 A9577 BCBST
73721 A9578 BCBST
73721 A9579 BCBST
73721 Q9953 BCBST
73722 01922 BCBST
73722 36000 BCBST
73722 36005 NCCI
73722 36011 BCBST
73722 36406 BCBST
73722 36410 BCBST
73722 73721 NCCI
73722 96360 NCCI
73722 96365 NCCI
73722 96372 NCCI
73722 96374 NCCI
73722 96375 NCCI
73722 96376 NCCI
73722 A9576 BCBST
Comprehensive ComponentCode Code Source
73722 A9577 BCBST
73722 A9578 BCBST
73722 A9579 BCBST
73722 J1642 NCCI
73722 Q9953 BCBST
73723 01922 BCBST
73723 36000 BCBST
73723 36005 NCCI
73723 36011 BCBST
73723 36406 BCBST
73723 36410 BCBST
73723 73721 BCBST
73723 73722 NCCI
73723 73723 BCBST
73723 73725 NCCI
73723 96360 NCCI
73723 96365 NCCI
73723 96372 NCCI
73723 96374 NCCI
73723 96375 NCCI
73723 96376 NCCI
73723 J1642 NCCI
73725 01916 NCCI
73725 01922 NCCI
73725 01924 NCCI
73725 01925 NCCI
73725 01926 NCCI
73725 36000 NCCI
73725 36005 NCCI
73725 36410 NCCI
73725 73718 NCCI
73725 73719 NCCI
73725 73721 NCCI
73725 73721 BCBST
73725 73722 NCCI
73725 76000 NCCI
73725 76001 NCCI
73725 76376 NCCI
73725 76377 NCCI
73725 76942 NCCI
73725 76998 NCCI
73725 77001 NCCI
73725 77002 NCCI
73725 96360 NCCI
73725 96365 NCCI
73725 96372 NCCI
73725 96374 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 22 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
73725 96375 NCCI
73725 96376 NCCI
73725 A9576 BCBST
73725 A9577 BCBST
73725 A9578 BCBST
73725 A9579 BCBST
73725 C8912 BCBST
73725 C8913 BCBST
73725 C8914 BCBST
73725 J1642 NCCI
73725 Q9953 BCBST
74010 74000 NCCI
74020 74000 NCCI
74020 74010 NCCI
74022 71010 NCCI
74022 74000 NCCI
74022 74010 NCCI
74022 74020 NCCI
74150 01922 NCCI
74150 72192 NCCI
74150 72193 NCCI
74150 72194 NCCI
74150 76380 NCCI
74160 01922 NCCI
74160 36000 NCCI
74160 36005 NCCI
74160 36011 NCCI
74160 36406 NCCI
74160 36410 NCCI
74160 72192 NCCI
74160 72193 NCCI
74160 72194 NCCI
74160 74150 NCCI
74160 76000 NCCI
74160 76001 NCCI
74160 76380 NCCI
74160 76942 NCCI
74160 76998 NCCI
74160 77001 NCCI
74160 77002 NCCI
74160 96360 NCCI
74160 96365 NCCI
74160 96372 NCCI
74160 96374 NCCI
74160 96375 NCCI
74160 96376 NCCI
74160 J1642 NCCI
Comprehensive ComponentCode Code Source
74170 01922 NCCI
74170 36000 NCCI
74170 36005 NCCI
74170 36011 NCCI
74170 36406 NCCI
74170 36410 NCCI
74170 72192 NCCI
74170 72192 NCCI
74170 72193 NCCI
74170 72193 NCCI
74170 72194 NCCI
74170 74150 NCCI
74170 74160 NCCI
74170 76000 NCCI
74170 76001 NCCI
74170 76380 NCCI
74170 76942 NCCI
74170 76998 NCCI
74170 77001 NCCI
74170 77002 NCCI
74170 96360 NCCI
74170 96365 NCCI
74170 96372 NCCI
74170 96374 NCCI
74170 96375 NCCI
74170 96376 NCCI
74170 J1642 NCCI
74174 01916 NCCI
74174 01922 NCCI
74174 01924 NCCI
74174 01925 NCCI
74174 01926 NCCI
74174 36000 NCCI
74174 36005 NCCI
74174 36011 NCCI
74174 36406 NCCI
74174 36410 NCCI
74174 72191 NCCI
74174 72192 NCCI
74174 72193 NCCI
74174 72194 NCCI
74174 73706 NCCI
74174 74150 NCCI
74174 74160 NCCI
74174 74170 NCCI
74174 74175 NCCI
74174 74176 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 23 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
74174 74177 NCCI
74174 74178 NCCI
74174 76000 NCCI
74174 76001 NCCI
74174 76376 NCCI
74174 76377 NCCI
74174 76380 NCCI
74174 76942 NCCI
74174 76998 NCCI
74174 77001 NCCI
74174 77002 NCCI
74174 96360 NCCI
74174 96365 NCCI
74174 96372 NCCI
74174 96374 NCCI
74174 96375 NCCI
74174 96376 NCCI
74174 J1642 NCCI
74175 01916 NCCI
74175 01922 BCBST
74175 01924 NCCI
74175 01925 NCCI
74175 01926 NCCI
74175 36000 BCBST
74175 36005 NCCI
74175 36011 NCCI
74175 36406 BCBST
74175 36410 BCBST
74175 72191 NCCI
74175 73706 NCCI
74175 74150 NCCI
74175 74150 BCBST
74175 74160 BCBST
74175 74160 NCCI
74175 74170 NCCI
74175 74170 BCBST
74175 74176 NCCI
74175 74177 NCCI
74175 74178 NCCI
74175 76000 NCCI
74175 76001 NCCI
74175 76376 NCCI
74175 76377 NCCI
74175 76380 NCCI
74175 76380 BCBST
74175 76942 NCCI
74175 76998 NCCI
Comprehensive ComponentCode Code Source
74175 77001 NCCI
74175 77002 NCCI
74175 96360 NCCI
74175 96365 NCCI
74175 96372 NCCI
74175 96374 NCCI
74175 96375 NCCI
74175 96376 NCCI
74175 J1642 NCCI
74176 01922 NCCI
74176 72192 NCCI
74176 72193 NCCI
74176 72194 NCCI
74176 74150 NCCI
74176 74160 NCCI
74176 74170 NCCI
74176 76380 NCCI
74177 01922 NCCI
74177 36000 NCCI
74177 36005 NCCI
74177 36011 NCCI
74177 36410 NCCI
74177 72192 NCCI
74177 72193 NCCI
74177 72194 NCCI
74177 74150 NCCI
74177 74160 NCCI
74177 74170 NCCI
74177 74176 NCCI
74177 76380 NCCI
74177 96360 NCCI
74177 96365 NCCI
74177 96374 NCCI
74177 J1642 NCCI
74178 01922 NCCI
74178 36000 NCCI
74178 36005 NCCI
74178 36011 NCCI
74178 36410 NCCI
74178 72192 NCCI
74178 72193 NCCI
74178 72194 NCCI
74178 74150 NCCI
74178 74160 NCCI
74178 74170 NCCI
74178 74176 NCCI
74178 74177 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 24 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
74178 76380 NCCI
74178 96360 NCCI
74178 96365 NCCI
74178 96374 NCCI
74178 J1642 NCCI
74181 01922 NCCI
74181 A9576 BCBST
74181 A9577 BCBST
74181 A9578 BCBST
74181 A9579 BCBST
74181 Q9953 BCBST
74182 01922 BCBST
74182 36000 BCBST
74182 36005 NCCI
74182 36011 BCBST
74182 36406 NCCI
74182 36410 BCBST
74182 36425 BCBST
74182 74181 NCCI
74182 76000 NCCI
74182 76001 NCCI
74182 76942 NCCI
74182 76998 NCCI
74182 77001 NCCI
74182 77002 NCCI
74182 96360 NCCI
74182 96365 NCCI
74182 96372 NCCI
74182 96374 NCCI
74182 96375 NCCI
74182 96376 NCCI
74182 A9576 BCBST
74182 A9577 BCBST
74182 A9578 BCBST
74182 A9579 BCBST
74182 J1642 NCCI
74182 Q9953 BCBST
74183 01922 BCBST
74183 36000 BCBST
74183 36005 NCCI
74183 36011 BCBST
74183 36406 NCCI
74183 36410 BCBST
74183 36425 BCBST
74183 74181 BCBST
74183 74182 NCCI
74183 74183 BCBST
Comprehensive ComponentCode Code Source
74183 74185 NCCI
74183 76000 NCCI
74183 76001 NCCI
74183 76942 NCCI
74183 76998 NCCI
74183 77001 NCCI
74183 77002 NCCI
74183 96360 NCCI
74183 96365 NCCI
74183 96372 NCCI
74183 96374 NCCI
74183 96375 NCCI
74183 96376 NCCI
74183 J1642 NCCI
74185 01916 NCCI
74185 01922 NCCI
74185 01924 NCCI
74185 01925 NCCI
74185 01926 NCCI
74185 36000 NCCI
74185 36000 NCCI
74185 36005 NCCI
74185 36410 NCCI
74185 74181 BCBST
74185 74181 NCCI
74185 74182 NCCI
74185 76000 NCCI
74185 76001 NCCI
74185 76376 NCCI
74185 76377 NCCI
74185 76942 NCCI
74185 76998 NCCI
74185 77001 NCCI
74185 77002 NCCI
74185 96360 NCCI
74185 96365 NCCI
74185 96372 NCCI
74185 96374 NCCI
74185 96375 NCCI
74185 96376 NCCI
74185 A9576 BCBST
74185 A9577 BCBST
74185 A9578 BCBST
74185 A9579 BCBST
74185 C8900 BCBST
74185 C8901 BCBST
74185 C8902 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: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 25 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
74185 J1642 NCCI
74185 Q9953 BCBST
74190 76000 NCCI
74190 76001 NCCI
74190 77001 NCCI
74190 77002 NCCI
74210 76000 NCCI
74210 76001 NCCI
74210 77001 NCCI
74220 74210 NCCI
74220 76000 NCCI
74220 76001 NCCI
74220 77001 NCCI
74230 74210 NCCI
74230 74220 NCCI
74230 76000 NCCI
74230 76000 BCBST
74230 76001 BCBST
74230 76001 NCCI
74230 77001 NCCI
74235 76000 NCCI
74235 76001 NCCI
74235 77001 NCCI
74235 77002 NCCI
74240 74000 NCCI
74240 74210 NCCI
74240 74220 NCCI
74240 74245 NCCI
74240 74249 NCCI
74240 76000 NCCI
74240 76000 BCBST
74240 76001 BCBST
74240 76001 NCCI
74240 77001 NCCI
74241 74000 NCCI
74241 74010 NCCI
74241 74210 NCCI
74241 74220 NCCI
74241 74240 NCCI
74241 74245 NCCI
74241 74249 NCCI
74241 76000 NCCI
74241 76000 BCBST
74241 76001 BCBST
74241 76001 NCCI
74241 77001 NCCI
74245 74000 NCCI
Comprehensive ComponentCode Code Source
74245 74010 NCCI
74245 74020 NCCI
74245 74210 NCCI
74245 74220 NCCI
74245 74250 NCCI
74245 76000 NCCI
74245 76000 BCBST
74245 76001 BCBST
74245 76001 NCCI
74245 77001 NCCI
74246 74000 NCCI
74246 74010 NCCI
74246 74210 NCCI
74246 74220 NCCI
74246 74240 NCCI
74246 74241 NCCI
74246 74245 NCCI
74246 74249 NCCI
74246 76000 NCCI
74246 76000 BCBST
74246 76001 BCBST
74246 76001 NCCI
74246 77001 NCCI
74247 74000 NCCI
74247 74010 NCCI
74247 74210 NCCI
74247 74220 NCCI
74247 74240 NCCI
74247 74241 NCCI
74247 74245 NCCI
74247 74246 NCCI
74247 74249 NCCI
74247 76000 NCCI
74247 76000 BCBST
74247 76001 BCBST
74247 76001 NCCI
74247 77001 NCCI
74249 74000 NCCI
74249 74210 NCCI
74249 74220 NCCI
74249 74245 NCCI
74249 74250 NCCI
74249 76000 NCCI
74249 76000 BCBST
74249 76001 BCBST
74249 76001 NCCI
74249 77001 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 26 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
74250 74000 NCCI
74250 76000 NCCI
74250 76000 BCBST
74250 76001 BCBST
74250 76001 NCCI
74250 77001 NCCI
74251 43752 NCCI
74251 74000 NCCI
74251 74250 NCCI
74251 76000 NCCI
74251 76000 BCBST
74251 76001 BCBST
74251 76001 NCCI
74251 77001 NCCI
74260 74246 NCCI
74260 74247 NCCI
74260 74249 NCCI
74260 76000 NCCI
74260 76000 BCBST
74260 76001 BCBST
74260 76001 NCCI
74260 77001 NCCI
74261 01922 NCCI
74261 72192 NCCI
74261 72193 NCCI
74261 72194 NCCI
74261 74150 NCCI
74261 74160 NCCI
74261 74170 NCCI
74261 74176 NCCI
74261 74177 NCCI
74261 74178 NCCI
74261 74263 NCCI
74261 76000 NCCI
74261 76001 NCCI
74261 76376 NCCI
74261 76377 NCCI
74261 77001 NCCI
74261 77002 NCCI
74262 01922 NCCI
74262 36000 NCCI
74262 36005 NCCI
74262 36410 NCCI
74262 72192 NCCI
74262 72193 NCCI
74262 72194 NCCI
74262 74150 NCCI
Comprehensive ComponentCode Code Source
74262 74160 NCCI
74262 74170 NCCI
74262 74176 NCCI
74262 74177 NCCI
74262 74178 NCCI
74262 74261 NCCI
74262 74263 NCCI
74262 76000 NCCI
74262 76001 NCCI
74262 76376 NCCI
74262 76377 NCCI
74262 76942 NCCI
74262 76998 NCCI
74262 77001 NCCI
74262 77002 NCCI
74262 96360 NCCI
74262 96365 NCCI
74262 96372 NCCI
74262 96374 NCCI
74262 96375 NCCI
74262 96376 NCCI
74263 01922 NCCI
74263 72192 NCCI
74263 72193 NCCI
74263 72194 NCCI
74263 74150 NCCI
74263 74160 NCCI
74263 74170 NCCI
74263 76000 NCCI
74263 76376 NCCI
74263 76377 NCCI
74270 74000 NCCI
74270 74010 NCCI
74270 74280 NCCI
74270 74283 NCCI
74270 76000 NCCI
74270 76001 NCCI
74270 76001 BCBST
74270 76942 NCCI
74270 76998 NCCI
74270 77001 NCCI
74280 74000 NCCI
74280 74010 NCCI
74280 74283 NCCI
74280 76000 NCCI
74280 76000 BCBST
74280 76001 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: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 27 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
74280 76001 NCCI
74280 77001 NCCI
74283 44705 NCCI
74283 76000 NCCI
74283 76000 BCBST
74283 76001 BCBST
74283 76001 NCCI
74283 77001 NCCI
74290 76000 NCCI
74290 76000 BCBST
74290 76001 BCBST
74290 76001 NCCI
74290 77001 NCCI
74291 76000 NCCI
74291 76000 BCBST
74291 76001 BCBST
74291 76001 NCCI
74291 77001 NCCI
74300 74290 NCCI
74300 74291 NCCI
74300 74305 NCCI
74300 76000 NCCI
74300 76001 NCCI
74300 77001 NCCI
74300 77002 NCCI
74301 74290 NCCI
74301 74291 NCCI
74301 74305 NCCI
74305 74290 NCCI
74305 74291 NCCI
74305 76000 NCCI
74305 76001 NCCI
74305 77001 NCCI
74305 77002 NCCI
74320 74290 NCCI
74320 74291 NCCI
74320 74300 NCCI
74320 74301 NCCI
74320 74305 NCCI
74320 76000 NCCI
74320 76001 NCCI
74320 77001 NCCI
74320 77002 NCCI
74327 76000 NCCI
74327 76001 NCCI
74327 77001 NCCI
74327 77002 NCCI
Comprehensive ComponentCode Code Source
74328 76000 NCCI
74328 76001 NCCI
74328 77001 NCCI
74328 77002 NCCI
74329 76000 NCCI
74329 76001 NCCI
74329 77001 NCCI
74329 77002 NCCI
74330 74328 NCCI
74330 74329 NCCI
74330 76000 NCCI
74330 76001 NCCI
74330 77001 NCCI
74330 77002 NCCI
74340 43752 NCCI
74340 74000 NCCI
74340 76000 NCCI
74340 76001 NCCI
74340 77001 NCCI
74340 77002 NCCI
74355 74000 NCCI
74355 76000 NCCI
74355 76001 NCCI
74355 77001 NCCI
74355 77002 NCCI
74360 74000 NCCI
74360 76000 NCCI
74360 76001 NCCI
74360 77001 NCCI
74360 77002 NCCI
74363 74000 NCCI
74363 76000 NCCI
74363 76001 NCCI
74363 77001 NCCI
74363 77002 NCCI
74400 36000 NCCI
74400 36011 NCCI
74400 36406 NCCI
74400 36410 NCCI
74400 36425 NCCI
74400 74000 NCCI
74400 74010 NCCI
74400 74022 NCCI
74400 74410 NCCI
74400 74420 NCCI
74400 76000 NCCI
74400 76001 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 28 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
74400 76001 BCBST
74400 76101 NCCI
74400 76102 NCCI
74400 76942 NCCI
74400 76998 NCCI
74400 77001 NCCI
74400 77002 NCCI
74400 96360 NCCI
74400 96365 NCCI
74400 96372 NCCI
74400 96374 NCCI
74400 96375 NCCI
74400 96376 NCCI
74410 36000 NCCI
74410 36011 NCCI
74410 36406 NCCI
74410 36410 NCCI
74410 36425 NCCI
74410 74000 NCCI
74410 74010 NCCI
74410 74020 NCCI
74410 74420 NCCI
74410 74425 NCCI
74410 76101 NCCI
74410 76102 NCCI
74410 96360 NCCI
74410 96365 NCCI
74410 96372 NCCI
74410 96374 NCCI
74410 96375 NCCI
74410 96376 NCCI
74415 36000 NCCI
74415 36011 NCCI
74415 36406 NCCI
74415 36410 NCCI
74415 36425 NCCI
74415 74000 NCCI
74415 74010 NCCI
74415 74020 NCCI
74415 74400 NCCI
74415 74410 NCCI
74415 74420 NCCI
74415 74425 NCCI
74415 76101 NCCI
74415 76102 NCCI
74415 96360 NCCI
74415 96365 NCCI
Comprehensive ComponentCode Code Source
74415 96372 NCCI
74415 96374 NCCI
74415 96375 NCCI
74415 96376 NCCI
74420 36000 NCCI
74420 36011 NCCI
74420 36410 NCCI
74420 36425 NCCI
74420 51701 NCCI
74420 51702 NCCI
74420 51703 NCCI
74420 57410 NCCI
74420 74000 NCCI
74420 74010 NCCI
74420 74020 NCCI
74420 74425 NCCI
74420 74430 NCCI
74420 74450 NCCI
74420 74455 NCCI
74420 76000 NCCI
74420 76001 NCCI
74420 76101 NCCI
74420 76102 NCCI
74420 76942 NCCI
74420 76998 NCCI
74420 77001 NCCI
74420 77002 NCCI
74420 96360 NCCI
74420 96365 NCCI
74420 96372 NCCI
74420 96374 NCCI
74420 96375 NCCI
74420 96376 NCCI
74420 P9612 NCCI
74425 36000 NCCI
74425 36011 NCCI
74425 36410 NCCI
74425 36425 NCCI
74425 74000 NCCI
74425 74010 NCCI
74425 74020 NCCI
74425 74400 NCCI
74425 76000 NCCI
74425 76001 NCCI
74425 76101 NCCI
74425 76102 NCCI
74425 77001 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 29 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
74425 77002 NCCI
74425 96360 NCCI
74425 96365 NCCI
74425 96372 NCCI
74425 96374 NCCI
74425 96375 NCCI
74425 96376 NCCI
74430 36000 NCCI
74430 36011 NCCI
74430 36410 NCCI
74430 36425 NCCI
74430 51701 NCCI
74430 51702 NCCI
74430 51703 NCCI
74430 74000 NCCI
74430 74455 NCCI
74430 76000 NCCI
74430 76001 NCCI
74430 77001 NCCI
74430 P9612 NCCI
74440 36000 NCCI
74440 36410 NCCI
74440 36425 NCCI
74440 74000 NCCI
74440 74450 NCCI
74440 76000 NCCI
74440 76001 NCCI
74440 76942 NCCI
74440 76998 NCCI
74440 77001 NCCI
74440 77002 NCCI
74445 36000 NCCI
74445 36410 NCCI
74445 74000 NCCI
74445 76000 NCCI
74445 76001 NCCI
74445 76942 NCCI
74445 76998 NCCI
74445 77001 NCCI
74445 77002 NCCI
74450 36000 NCCI
74450 36011 NCCI
74450 36410 NCCI
74450 36425 NCCI
74450 51600 NCCI
74450 51701 NCCI
74450 51702 NCCI
Comprehensive ComponentCode Code Source
74450 51703 NCCI
74450 74000 NCCI
74450 76000 NCCI
74450 76001 NCCI
74450 77001 NCCI
74450 77002 NCCI
74450 P9612 NCCI
74455 36000 NCCI
74455 36011 NCCI
74455 36410 NCCI
74455 36425 NCCI
74455 51701 NCCI
74455 51702 NCCI
74455 51703 NCCI
74455 74000 NCCI
74455 74450 NCCI
74455 76000 NCCI
74455 76001 NCCI
74455 77001 NCCI
74455 P9612 NCCI
74470 36000 NCCI
74470 36011 NCCI
74470 36410 NCCI
74470 36425 NCCI
74470 76000 NCCI
74470 76001 NCCI
74470 77001 NCCI
74470 77002 NCCI
74470 96372 NCCI
74470 96374 NCCI
74470 96375 NCCI
74470 96376 NCCI
74475 36000 NCCI
74475 36011 NCCI
74475 36410 NCCI
74475 36425 NCCI
74475 76000 NCCI
74475 76001 NCCI
74475 76942 NCCI
74475 77001 NCCI
74475 77002 NCCI
74475 96372 NCCI
74475 96374 NCCI
74475 96375 NCCI
74475 96376 NCCI
74480 36000 NCCI
74480 36011 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 30 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
74480 36410 NCCI
74480 36425 NCCI
74480 74475 NCCI
74480 76000 NCCI
74480 76001 NCCI
74480 76942 NCCI
74480 77001 NCCI
74480 77002 NCCI
74480 96372 NCCI
74480 96374 NCCI
74480 96375 NCCI
74480 96376 NCCI
74485 36000 NCCI
74485 36011 NCCI
74485 36410 NCCI
74485 36425 NCCI
74485 51701 NCCI
74485 51702 NCCI
74485 51703 NCCI
74485 52351 BCBST
74485 76000 NCCI
74485 76001 NCCI
74485 76942 NCCI
74485 77001 NCCI
74485 77002 NCCI
74485 96372 NCCI
74485 96374 NCCI
74485 96375 NCCI
74485 96376 NCCI
74485 P9612 NCCI
74740 00952 NCCI
74740 76000 NCCI
74740 76001 NCCI
74740 77001 NCCI
74742 74740 NCCI
74742 76000 NCCI
74742 76001 NCCI
74742 77001 NCCI
74742 77002 NCCI
74775 76000 NCCI
74775 76001 NCCI
74775 77001 NCCI
74775 77002 NCCI
75557 76376 NCCI
75557 76377 NCCI
75559 75557 NCCI
75559 76376 NCCI
Comprehensive ComponentCode Code Source
75559 76377 NCCI
75561 36000 NCCI
75561 36410 NCCI
75561 75557 NCCI
75561 75559 NCCI
75561 76000 NCCI
75561 76001 NCCI
75561 76376 NCCI
75561 76377 NCCI
75561 76942 NCCI
75561 76998 NCCI
75561 77001 NCCI
75561 77002 NCCI
75561 96360 NCCI
75561 96365 NCCI
75561 96372 NCCI
75561 96374 NCCI
75563 36000 NCCI
75563 36410 NCCI
75563 75557 NCCI
75563 75559 NCCI
75563 75561 NCCI
75563 76000 NCCI
75563 76001 NCCI
75563 76376 NCCI
75563 76377 NCCI
75563 76942 NCCI
75563 76998 NCCI
75563 77001 NCCI
75563 77002 NCCI
75563 96360 NCCI
75563 96365 NCCI
75563 96372 NCCI
75563 96374 NCCI
75565 76376 NCCI
75565 76377 NCCI
75571 01922 NCCI
75571 76000 NCCI
75571 76001 NCCI
75571 76120 NCCI
75571 76125 NCCI
75571 76376 NCCI
75571 76377 NCCI
75571 77001 NCCI
75571 77002 NCCI
75571 93000 NCCI
75571 93005 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 31 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75571 93010 NCCI
75571 93040 NCCI
75571 93041 NCCI
75571 93042 NCCI
75572 01922 NCCI
75572 36000 NCCI
75572 36005 NCCI
75572 36410 NCCI
75572 71250 NCCI
75572 71260 NCCI
75572 71270 NCCI
75572 75571 NCCI
75572 76000 NCCI
75572 76001 NCCI
75572 76120 NCCI
75572 76125 NCCI
75572 76376 NCCI
75572 76377 NCCI
75572 76942 NCCI
75572 76998 NCCI
75572 77001 NCCI
75572 77002 NCCI
75572 93000 NCCI
75572 93005 NCCI
75572 93010 NCCI
75572 93040 NCCI
75572 93041 NCCI
75572 93042 NCCI
75572 96360 NCCI
75572 96365 NCCI
75572 96372 NCCI
75572 96374 NCCI
75572 96375 NCCI
75572 96376 NCCI
75573 01922 NCCI
75573 36000 NCCI
75573 36005 NCCI
75573 36410 NCCI
75573 71250 NCCI
75573 71260 NCCI
75573 71270 NCCI
75573 75571 NCCI
75573 75572 NCCI
75573 75574 NCCI
75573 76000 NCCI
75573 76001 NCCI
75573 76120 NCCI
Comprehensive ComponentCode Code Source
75573 76125 NCCI
75573 76376 NCCI
75573 76377 NCCI
75573 76942 NCCI
75573 76998 NCCI
75573 77001 NCCI
75573 77002 NCCI
75573 93000 NCCI
75573 93005 NCCI
75573 93010 NCCI
75573 93040 NCCI
75573 93041 NCCI
75573 93042 NCCI
75573 96360 NCCI
75573 96365 NCCI
75573 96372 NCCI
75573 96374 NCCI
75573 96375 NCCI
75573 96376 NCCI
75574 01922 NCCI
75574 36000 NCCI
75574 36005 NCCI
75574 36410 NCCI
75574 71250 NCCI
75574 71260 NCCI
75574 71270 NCCI
75574 75571 NCCI
75574 75572 NCCI
75574 76000 NCCI
75574 76001 NCCI
75574 76120 NCCI
75574 76125 NCCI
75574 76376 NCCI
75574 76377 NCCI
75574 76942 NCCI
75574 76998 NCCI
75574 77001 NCCI
75574 77002 NCCI
75574 93000 NCCI
75574 93005 NCCI
75574 93010 NCCI
75574 93040 NCCI
75574 93041 NCCI
75574 93042 NCCI
75574 96360 NCCI
75574 96365 NCCI
75574 96372 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 32 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75574 96374 NCCI
75574 96375 NCCI
75574 96376 NCCI
75600 01916 NCCI
75600 01924 NCCI
75600 01925 NCCI
75600 01926 NCCI
75600 35201 NCCI
75600 35206 NCCI
75600 35226 NCCI
75600 35261 NCCI
75600 35266 NCCI
75600 35286 NCCI
75600 36000 NCCI
75600 36005 NCCI
75600 36410 NCCI
75600 36500 NCCI
75600 75827 NCCI
75600 75893 NCCI
75600 75896 NCCI
75600 76000 NCCI
75600 76001 NCCI
75600 76942 NCCI
75600 76998 NCCI
75600 77001 NCCI
75600 77002 NCCI
75600 93567 NCCI
75600 96372 NCCI
75600 96376 NCCI
75600 J1642 NCCI
75605 01916 NCCI
75605 01924 NCCI
75605 01925 NCCI
75605 01926 NCCI
75605 35201 NCCI
75605 35206 NCCI
75605 35226 NCCI
75605 35261 NCCI
75605 35266 NCCI
75605 35286 NCCI
75605 36000 NCCI
75605 36005 NCCI
75605 36410 NCCI
75605 36500 NCCI
75605 75600 NCCI
75605 75827 NCCI
75605 75893 NCCI
Comprehensive ComponentCode Code Source
75605 75896 NCCI
75605 76000 NCCI
75605 76001 NCCI
75605 76942 NCCI
75605 76998 NCCI
75605 77001 NCCI
75605 77002 NCCI
75605 93567 NCCI
75605 96372 NCCI
75605 96376 NCCI
75625 01916 NCCI
75625 01924 NCCI
75625 01925 NCCI
75625 01926 NCCI
75625 35201 NCCI
75625 35206 NCCI
75625 35226 NCCI
75625 35261 NCCI
75625 35266 NCCI
75625 35286 NCCI
75625 36000 NCCI
75625 36005 NCCI
75625 36410 NCCI
75625 36500 NCCI
75625 75825 NCCI
75625 75893 NCCI
75625 75896 NCCI
75625 76000 NCCI
75625 76001 NCCI
75625 76942 NCCI
75625 76998 NCCI
75625 77001 NCCI
75625 77002 NCCI
75625 93567 NCCI
75625 96372 NCCI
75625 96376 NCCI
75630 01916 NCCI
75630 01924 NCCI
75630 01925 NCCI
75630 01926 NCCI
75630 35201 NCCI
75630 35206 NCCI
75630 35226 NCCI
75630 35261 NCCI
75630 35266 NCCI
75630 35286 NCCI
75630 36000 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 33 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75630 36005 NCCI
75630 36410 NCCI
75630 36500 NCCI
75630 75625 NCCI
75630 75716 NCCI
75630 75820 NCCI
75630 75822 NCCI
75630 75825 NCCI
75630 75893 NCCI
75630 75896 NCCI
75630 76000 NCCI
75630 76001 NCCI
75630 76942 NCCI
75630 76998 NCCI
75630 77001 NCCI
75630 77002 NCCI
75630 93567 NCCI
75630 96372 NCCI
75630 96376 NCCI
75635 01916 NCCI
75635 01922 BCBST
75635 01924 NCCI
75635 01925 NCCI
75635 01926 NCCI
75635 36000 BCBST
75635 36005 NCCI
75635 36011 NCCI
75635 36406 BCBST
75635 36410 BCBST
75635 36500 NCCI
75635 72191 NCCI
75635 73700 NCCI
75635 73701 NCCI
75635 73702 NCCI
75635 73706 NCCI
75635 74150 NCCI
75635 74150 BCBST
75635 74160 BCBST
75635 74160 NCCI
75635 74170 NCCI
75635 74170 BCBST
75635 74174 NCCI
75635 74175 NCCI
75635 75893 NCCI
75635 75896 NCCI
75635 76000 NCCI
75635 76001 NCCI
Comprehensive ComponentCode Code Source
75635 76376 NCCI
75635 76377 NCCI
75635 76942 NCCI
75635 76998 NCCI
75635 77001 NCCI
75635 77002 NCCI
75635 93567 NCCI
75635 96360 NCCI
75635 96365 NCCI
75635 96372 NCCI
75635 96374 NCCI
75635 96375 NCCI
75635 96376 NCCI
75635 G0288 BCBST
75658 01916 NCCI
75658 01924 NCCI
75658 01925 NCCI
75658 01926 NCCI
75658 35201 NCCI
75658 35206 NCCI
75658 35226 NCCI
75658 35261 NCCI
75658 35266 NCCI
75658 35286 NCCI
75658 36000 NCCI
75658 36005 NCCI
75658 36410 NCCI
75658 36500 NCCI
75658 75820 NCCI
75658 75822 NCCI
75658 75893 NCCI
75658 75896 NCCI
75658 76000 NCCI
75658 76001 NCCI
75658 76942 NCCI
75658 76998 NCCI
75658 77001 NCCI
75658 77002 NCCI
75658 96372 NCCI
75658 96376 NCCI
75660 75660 CPT
75665 75665 CPT
75676 75676 CPT
75705 01916 NCCI
75705 01924 NCCI
75705 01925 NCCI
75705 01926 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 34 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75705 01935 NCCI
75705 01936 NCCI
75705 35201 NCCI
75705 35206 NCCI
75705 35226 NCCI
75705 35261 NCCI
75705 35266 NCCI
75705 35286 NCCI
75705 36000 NCCI
75705 36005 NCCI
75705 36410 NCCI
75705 36500 NCCI
75705 75893 NCCI
75705 75896 NCCI
75705 76000 NCCI
75705 76001 NCCI
75705 76942 NCCI
75705 76998 NCCI
75705 77001 NCCI
75705 77002 NCCI
75705 96372 NCCI
75705 96376 NCCI
75710 01916 NCCI
75710 01924 NCCI
75710 01925 NCCI
75710 01926 NCCI
75710 35201 NCCI
75710 35206 BCBST
75710 35226 BCBST
75710 35261 NCCI
75710 35266 NCCI
75710 35286 NCCI
75710 36000 NCCI
75710 36005 NCCI
75710 36410 NCCI
75710 36500 NCCI
75710 75630 NCCI
75710 75710 CPT
75710 75820 NCCI
75710 75822 NCCI
75710 75893 NCCI
75710 75896 NCCI
75710 76000 NCCI
75710 76001 NCCI
75710 76942 NCCI
75710 76998 NCCI
75710 77001 NCCI
Comprehensive ComponentCode Code Source
75710 77002 NCCI
75710 96372 NCCI
75710 96376 NCCI
75716 01916 NCCI
75716 01924 NCCI
75716 01925 NCCI
75716 01926 NCCI
75716 35201 NCCI
75716 35206 BCBST
75716 35226 BCBST
75716 35261 NCCI
75716 35266 NCCI
75716 35286 NCCI
75716 36000 NCCI
75716 36005 NCCI
75716 36410 NCCI
75716 36500 NCCI
75716 75710 NCCI
75716 75820 NCCI
75716 75822 NCCI
75716 75893 NCCI
75716 75896 NCCI
75716 76000 NCCI
75716 76001 NCCI
75716 76942 NCCI
75716 76998 NCCI
75716 77001 NCCI
75716 77002 NCCI
75716 96372 NCCI
75716 96376 NCCI
75726 01916 NCCI
75726 01924 NCCI
75726 01925 NCCI
75726 01926 NCCI
75726 35201 NCCI
75726 35206 NCCI
75726 35226 NCCI
75726 35261 NCCI
75726 35266 NCCI
75726 35286 NCCI
75726 36000 NCCI
75726 36005 NCCI
75726 36410 NCCI
75726 36500 NCCI
75726 75810 NCCI
75726 75889 NCCI
75726 75891 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 35 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75726 75893 NCCI
75726 75896 NCCI
75726 76000 NCCI
75726 76001 NCCI
75726 76942 NCCI
75726 76998 NCCI
75726 77001 NCCI
75726 77002 NCCI
75726 96372 NCCI
75726 96376 NCCI
75731 01916 NCCI
75731 01924 NCCI
75731 01925 NCCI
75731 01926 NCCI
75731 35201 NCCI
75731 35206 NCCI
75731 35226 NCCI
75731 35261 NCCI
75731 35266 NCCI
75731 35286 NCCI
75731 36000 NCCI
75731 36005 NCCI
75731 36410 NCCI
75731 36500 NCCI
75731 75731 CPT
75731 75840 NCCI
75731 75842 NCCI
75731 75893 NCCI
75731 75896 NCCI
75731 76000 NCCI
75731 76001 NCCI
75731 76942 NCCI
75731 76998 NCCI
75731 77001 NCCI
75731 77002 NCCI
75731 96372 NCCI
75731 96376 NCCI
75733 01916 NCCI
75733 01924 NCCI
75733 01925 NCCI
75733 01926 NCCI
75733 35201 NCCI
75733 35206 NCCI
75733 35226 NCCI
75733 35261 NCCI
75733 35266 NCCI
75733 35286 NCCI
Comprehensive ComponentCode Code Source
75733 36000 NCCI
75733 36005 NCCI
75733 36410 NCCI
75733 36500 NCCI
75733 75731 NCCI
75733 75840 NCCI
75733 75842 NCCI
75733 75893 NCCI
75733 75896 NCCI
75733 76000 NCCI
75733 76001 NCCI
75733 76942 NCCI
75733 76998 NCCI
75733 77001 NCCI
75733 77002 NCCI
75733 96372 NCCI
75733 96376 NCCI
75736 01916 NCCI
75736 01924 NCCI
75736 01925 NCCI
75736 01926 NCCI
75736 35201 NCCI
75736 35206 NCCI
75736 35226 NCCI
75736 35261 NCCI
75736 35266 NCCI
75736 35286 NCCI
75736 36000 NCCI
75736 36005 NCCI
75736 36410 NCCI
75736 36500 NCCI
75736 75825 NCCI
75736 75893 NCCI
75736 75896 NCCI
75736 76000 NCCI
75736 76001 NCCI
75736 76942 NCCI
75736 76998 NCCI
75736 77001 NCCI
75736 77002 NCCI
75736 96372 NCCI
75736 96376 NCCI
75736 G0278 BCBST
75741 01916 NCCI
75741 01924 NCCI
75741 01925 NCCI
75741 01926 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 36 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75741 35201 NCCI
75741 35206 NCCI
75741 35226 NCCI
75741 35261 NCCI
75741 35266 NCCI
75741 35286 NCCI
75741 36000 NCCI
75741 36005 NCCI
75741 36410 NCCI
75741 36500 NCCI
75741 75741 CPT
75741 75746 NCCI
75741 75893 NCCI
75741 75896 NCCI
75741 76000 NCCI
75741 76001 NCCI
75741 76942 NCCI
75741 76998 NCCI
75741 77001 NCCI
75741 77002 NCCI
75741 93568 NCCI
75741 96372 NCCI
75741 96376 NCCI
75743 01916 NCCI
75743 01924 NCCI
75743 01925 NCCI
75743 01926 NCCI
75743 35201 NCCI
75743 35206 NCCI
75743 35226 NCCI
75743 35261 NCCI
75743 35266 NCCI
75743 35286 NCCI
75743 36000 NCCI
75743 36005 NCCI
75743 36410 NCCI
75743 36500 NCCI
75743 75741 NCCI
75743 75746 NCCI
75743 75893 NCCI
75743 75896 NCCI
75743 76000 NCCI
75743 76001 NCCI
75743 76942 NCCI
75743 76998 NCCI
75743 77001 NCCI
75743 77002 NCCI
Comprehensive ComponentCode Code Source
75743 93568 NCCI
75743 96372 NCCI
75743 96376 NCCI
75746 01916 NCCI
75746 01924 NCCI
75746 01925 NCCI
75746 01926 NCCI
75746 35201 NCCI
75746 35206 NCCI
75746 35226 NCCI
75746 35261 NCCI
75746 35266 NCCI
75746 35286 NCCI
75746 36000 NCCI
75746 36005 NCCI
75746 36410 NCCI
75746 36500 NCCI
75746 75893 NCCI
75746 75896 NCCI
75746 76000 NCCI
75746 76001 NCCI
75746 76942 NCCI
75746 76998 NCCI
75746 77001 NCCI
75746 77002 NCCI
75746 93568 NCCI
75746 96372 NCCI
75746 96376 NCCI
75756 01916 NCCI
75756 01924 NCCI
75756 01925 NCCI
75756 01926 NCCI
75756 35201 NCCI
75756 35206 NCCI
75756 35226 NCCI
75756 35261 NCCI
75756 35266 NCCI
75756 35286 NCCI
75756 36000 NCCI
75756 36005 NCCI
75756 36410 NCCI
75756 36500 NCCI
75756 75893 NCCI
75756 75896 NCCI
75756 76000 NCCI
75756 76001 NCCI
75756 76942 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 37 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75756 76998 NCCI
75756 77001 NCCI
75756 77002 NCCI
75756 96372 NCCI
75756 96376 NCCI
75774 01916 NCCI
75774 01924 NCCI
75774 01925 NCCI
75774 01926 NCCI
75774 35201 NCCI
75774 35206 NCCI
75774 35226 NCCI
75774 35261 NCCI
75774 35266 NCCI
75774 35286 NCCI
75774 36005 NCCI
75774 75896 NCCI
75774 76000 NCCI
75774 76001 NCCI
75774 76942 NCCI
75774 76998 NCCI
75774 77001 NCCI
75774 77002 NCCI
75774 96372 NCCI
75791 01916 NCCI
75791 01924 NCCI
75791 01930 NCCI
75791 35206 NCCI
75791 35226 NCCI
75791 35236 NCCI
75791 35256 NCCI
75791 35266 NCCI
75791 35286 NCCI
75791 36000 NCCI
75791 36005 NCCI
75791 36410 NCCI
75791 75658 NCCI
75791 75820 NCCI
75791 75822 NCCI
75791 75825 NCCI
75791 75827 NCCI
75791 75896 NCCI
75791 76000 NCCI
75791 76001 NCCI
75791 76937 NCCI
75791 76942 NCCI
75791 76998 NCCI
Comprehensive ComponentCode Code Source
75791 77001 NCCI
75791 77002 NCCI
75791 77012 NCCI
75791 77021 NCCI
75791 96360 NCCI
75791 96365 NCCI
75791 96372 NCCI
75791 96374 NCCI
75791 96375 NCCI
75791 96376 NCCI
75801 01916 NCCI
75801 01924 NCCI
75801 01925 NCCI
75801 01926 NCCI
75801 36005 NCCI
75801 75801 CPT
75801 76000 NCCI
75801 76001 NCCI
75801 76942 NCCI
75801 76998 NCCI
75801 77001 NCCI
75801 77002 NCCI
75801 96372 NCCI
75803 01916 NCCI
75803 01924 NCCI
75803 01925 NCCI
75803 01926 NCCI
75803 36005 NCCI
75803 75801 NCCI
75803 76000 NCCI
75803 76001 NCCI
75803 76942 NCCI
75803 76998 NCCI
75803 77001 NCCI
75803 77002 NCCI
75803 96372 NCCI
75805 01916 NCCI
75805 01924 NCCI
75805 01925 NCCI
75805 01926 NCCI
75805 36005 NCCI
75805 75805 CPT
75805 76000 NCCI
75805 76001 NCCI
75805 76810 NCCI
75805 76942 NCCI
75805 76998 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 38 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75805 77001 NCCI
75805 77002 NCCI
75805 96372 NCCI
75807 01916 NCCI
75807 01924 NCCI
75807 01925 NCCI
75807 01926 NCCI
75807 36005 NCCI
75807 75805 NCCI
75807 76000 NCCI
75807 76001 NCCI
75807 76942 NCCI
75807 76998 NCCI
75807 77001 NCCI
75807 77002 NCCI
75807 96372 NCCI
75809 01916 NCCI
75809 01924 NCCI
75809 01925 NCCI
75809 01926 NCCI
75809 36005 NCCI
75809 76000 NCCI
75809 76001 NCCI
75809 76942 NCCI
75809 76998 NCCI
75809 77001 NCCI
75809 77002 NCCI
75810 01916 NCCI
75810 01924 NCCI
75810 01925 NCCI
75810 01926 NCCI
75810 35201 NCCI
75810 35206 NCCI
75810 35226 NCCI
75810 35261 NCCI
75810 35266 NCCI
75810 35286 NCCI
75810 36000 NCCI
75810 36005 NCCI
75810 36410 NCCI
75810 36500 NCCI
75810 75896 NCCI
75810 76000 NCCI
75810 76001 NCCI
75810 76942 NCCI
75810 76998 NCCI
75810 77001 NCCI
Comprehensive ComponentCode Code Source
75810 77002 NCCI
75810 96360 NCCI
75810 96365 NCCI
75810 96372 NCCI
75810 96374 NCCI
75810 96375 NCCI
75810 96376 NCCI
75820 01916 NCCI
75820 01924 NCCI
75820 01925 NCCI
75820 01926 NCCI
75820 35201 NCCI
75820 35206 BCBST
75820 35226 BCBST
75820 35261 NCCI
75820 35266 NCCI
75820 35286 NCCI
75820 36000 NCCI
75820 36410 NCCI
75820 36500 NCCI
75820 75820 CPT
75820 75896 NCCI
75820 76000 NCCI
75820 76001 NCCI
75820 76942 NCCI
75820 76998 NCCI
75820 77002 NCCI
75820 78456 NCCI
75820 78457 NCCI
75820 78458 NCCI
75820 96360 NCCI
75820 96365 NCCI
75820 96372 NCCI
75820 96374 NCCI
75820 96375 NCCI
75820 96376 NCCI
75822 01916 NCCI
75822 01924 NCCI
75822 01925 NCCI
75822 01926 NCCI
75822 35201 NCCI
75822 35206 BCBST
75822 35226 BCBST
75822 35261 NCCI
75822 35266 NCCI
75822 35286 NCCI
75822 36000 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 39 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75822 36410 NCCI
75822 36500 NCCI
75822 75820 NCCI
75822 75896 NCCI
75822 76000 NCCI
75822 76001 NCCI
75822 76942 NCCI
75822 76998 NCCI
75822 77002 NCCI
75822 96360 NCCI
75822 96365 NCCI
75822 96372 NCCI
75822 96374 NCCI
75822 96375 NCCI
75822 96376 NCCI
75825 01916 NCCI
75825 01924 NCCI
75825 01925 NCCI
75825 01926 NCCI
75825 35201 NCCI
75825 35206 NCCI
75825 35226 NCCI
75825 35261 NCCI
75825 35266 NCCI
75825 35286 NCCI
75825 36000 NCCI
75825 36005 NCCI
75825 36410 NCCI
75825 36500 NCCI
75825 36598 NCCI
75825 75896 NCCI
75825 76000 NCCI
75825 76001 NCCI
75825 76942 NCCI
75825 76998 NCCI
75825 77002 NCCI
75825 96360 NCCI
75825 96365 NCCI
75825 96372 NCCI
75825 96374 NCCI
75825 96375 NCCI
75825 96376 NCCI
75827 01916 NCCI
75827 01924 NCCI
75827 01925 NCCI
75827 01926 NCCI
75827 35201 NCCI
Comprehensive ComponentCode Code Source
75827 35206 NCCI
75827 35226 NCCI
75827 35261 NCCI
75827 35266 NCCI
75827 35286 NCCI
75827 36000 NCCI
75827 36005 NCCI
75827 36410 NCCI
75827 36500 NCCI
75827 36598 NCCI
75827 75896 NCCI
75827 76000 NCCI
75827 76001 NCCI
75827 76942 NCCI
75827 76998 NCCI
75827 77002 NCCI
75827 96360 NCCI
75827 96365 NCCI
75827 96372 NCCI
75827 96374 NCCI
75827 96375 NCCI
75827 96376 NCCI
75831 01916 NCCI
75831 01924 NCCI
75831 01925 NCCI
75831 01926 NCCI
75831 35201 NCCI
75831 35206 NCCI
75831 35226 NCCI
75831 35261 NCCI
75831 35266 NCCI
75831 35286 NCCI
75831 36000 NCCI
75831 36005 NCCI
75831 36410 NCCI
75831 36500 NCCI
75831 75831 CPT
75831 75896 NCCI
75831 76000 NCCI
75831 76001 NCCI
75831 76942 NCCI
75831 76998 NCCI
75831 77001 NCCI
75831 77002 NCCI
75831 96360 NCCI
75831 96365 NCCI
75831 96372 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 40 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75831 96374 NCCI
75831 96375 NCCI
75831 96376 NCCI
75833 01916 NCCI
75833 01924 NCCI
75833 01925 NCCI
75833 01926 NCCI
75833 35201 NCCI
75833 35206 NCCI
75833 35226 NCCI
75833 35261 NCCI
75833 35266 NCCI
75833 35286 NCCI
75833 36000 NCCI
75833 36005 NCCI
75833 36410 NCCI
75833 36500 NCCI
75833 75831 NCCI
75833 75896 NCCI
75833 76000 NCCI
75833 76001 NCCI
75833 76942 NCCI
75833 76998 NCCI
75833 77001 NCCI
75833 77002 NCCI
75833 96360 NCCI
75833 96365 NCCI
75833 96372 NCCI
75833 96374 NCCI
75833 96375 NCCI
75833 96376 NCCI
75840 01916 NCCI
75840 01924 NCCI
75840 01925 NCCI
75840 01926 NCCI
75840 35201 NCCI
75840 35206 NCCI
75840 35226 NCCI
75840 35261 NCCI
75840 35266 NCCI
75840 35286 NCCI
75840 36000 NCCI
75840 36005 NCCI
75840 36410 NCCI
75840 36500 NCCI
75840 75840 CPT
75840 75896 NCCI
Comprehensive ComponentCode Code Source
75840 76000 NCCI
75840 76001 NCCI
75840 76942 NCCI
75840 76998 NCCI
75840 77001 NCCI
75840 77002 NCCI
75840 96360 NCCI
75840 96365 NCCI
75840 96372 NCCI
75840 96374 NCCI
75840 96375 NCCI
75840 96376 NCCI
75842 01916 NCCI
75842 01924 NCCI
75842 01925 NCCI
75842 01926 NCCI
75842 35201 NCCI
75842 35206 NCCI
75842 35226 NCCI
75842 35261 NCCI
75842 35266 NCCI
75842 35286 NCCI
75842 36000 NCCI
75842 36005 NCCI
75842 36410 NCCI
75842 36500 NCCI
75842 75840 NCCI
75842 75896 NCCI
75842 76000 NCCI
75842 76001 NCCI
75842 76942 NCCI
75842 76998 NCCI
75842 77001 NCCI
75842 77002 NCCI
75842 96360 NCCI
75842 96365 NCCI
75842 96372 NCCI
75842 96374 NCCI
75842 96375 NCCI
75842 96376 NCCI
75860 01916 NCCI
75860 01924 NCCI
75860 01925 NCCI
75860 01926 NCCI
75860 35201 NCCI
75860 35206 NCCI
75860 35226 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 41 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75860 35261 NCCI
75860 35266 NCCI
75860 35286 NCCI
75860 36000 NCCI
75860 36005 NCCI
75860 36410 NCCI
75860 36500 NCCI
75860 75896 NCCI
75860 76000 NCCI
75860 76001 NCCI
75860 76942 NCCI
75860 76998 NCCI
75860 77001 NCCI
75860 77002 NCCI
75860 96360 NCCI
75860 96365 NCCI
75860 96372 NCCI
75860 96374 NCCI
75860 96375 NCCI
75860 96376 NCCI
75870 01916 NCCI
75870 01924 NCCI
75870 01925 NCCI
75870 01926 NCCI
75870 35201 NCCI
75870 35206 NCCI
75870 35226 NCCI
75870 35261 NCCI
75870 35266 NCCI
75870 35286 NCCI
75870 36000 NCCI
75870 36005 NCCI
75870 36410 NCCI
75870 36500 NCCI
75870 75860 NCCI
75870 75896 NCCI
75870 76000 NCCI
75870 76001 NCCI
75870 76942 NCCI
75870 76998 NCCI
75870 77001 NCCI
75870 77002 NCCI
75870 96360 NCCI
75870 96365 NCCI
75870 96372 NCCI
75870 96374 NCCI
75870 96375 NCCI
Comprehensive ComponentCode Code Source
75870 96376 NCCI
75872 01916 NCCI
75872 01924 NCCI
75872 01925 NCCI
75872 01926 NCCI
75872 35201 NCCI
75872 35206 NCCI
75872 35226 NCCI
75872 35261 NCCI
75872 35266 NCCI
75872 35286 NCCI
75872 36000 NCCI
75872 36005 NCCI
75872 36410 NCCI
75872 36500 NCCI
75872 75896 NCCI
75872 76000 NCCI
75872 76001 NCCI
75872 76942 NCCI
75872 76998 NCCI
75872 77001 NCCI
75872 77002 NCCI
75872 96360 NCCI
75872 96365 NCCI
75872 96372 NCCI
75872 96374 NCCI
75872 96375 NCCI
75872 96376 NCCI
75880 01916 NCCI
75880 01924 NCCI
75880 01925 NCCI
75880 01926 NCCI
75880 35201 NCCI
75880 35206 NCCI
75880 35226 NCCI
75880 35261 NCCI
75880 35266 NCCI
75880 35286 NCCI
75880 36000 NCCI
75880 36005 NCCI
75880 36410 NCCI
75880 36500 NCCI
75880 75896 NCCI
75880 76000 NCCI
75880 76001 NCCI
75880 76942 NCCI
75880 76998 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 42 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75880 77001 NCCI
75880 77002 NCCI
75880 78456 NCCI
75880 78457 NCCI
75880 78458 NCCI
75880 96360 NCCI
75880 96365 NCCI
75880 96372 NCCI
75880 96374 NCCI
75880 96375 NCCI
75880 96376 NCCI
75885 01916 NCCI
75885 01924 NCCI
75885 01925 NCCI
75885 01926 NCCI
75885 35201 NCCI
75885 35206 NCCI
75885 35226 NCCI
75885 35261 NCCI
75885 35266 NCCI
75885 35286 NCCI
75885 36000 NCCI
75885 36005 NCCI
75885 36410 NCCI
75885 36500 NCCI
75885 75887 NCCI
75885 75896 NCCI
75885 76000 NCCI
75885 76001 NCCI
75885 76942 NCCI
75885 76998 NCCI
75885 77001 NCCI
75885 77002 NCCI
75885 96360 NCCI
75885 96365 NCCI
75885 96372 NCCI
75885 96374 NCCI
75885 96375 NCCI
75885 96376 NCCI
75887 01916 NCCI
75887 01924 NCCI
75887 01925 NCCI
75887 01926 NCCI
75887 35201 NCCI
75887 35206 NCCI
75887 35226 NCCI
75887 35261 NCCI
Comprehensive ComponentCode Code Source
75887 35266 NCCI
75887 35286 NCCI
75887 36000 NCCI
75887 36005 NCCI
75887 36410 NCCI
75887 36500 NCCI
75887 75896 NCCI
75887 76000 NCCI
75887 76001 NCCI
75887 76942 NCCI
75887 76998 NCCI
75887 77001 NCCI
75887 77002 NCCI
75887 96360 NCCI
75887 96365 NCCI
75887 96372 NCCI
75887 96374 NCCI
75887 96375 NCCI
75887 96376 NCCI
75889 01916 NCCI
75889 01924 NCCI
75889 01925 NCCI
75889 01926 NCCI
75889 35201 NCCI
75889 35206 NCCI
75889 35226 NCCI
75889 35261 NCCI
75889 35266 NCCI
75889 35286 NCCI
75889 36000 NCCI
75889 36005 NCCI
75889 36410 NCCI
75889 36500 NCCI
75889 75891 NCCI
75889 75896 NCCI
75889 76000 NCCI
75889 76001 NCCI
75889 76942 NCCI
75889 76998 NCCI
75889 77001 NCCI
75889 77002 NCCI
75889 96360 NCCI
75889 96365 NCCI
75889 96372 NCCI
75889 96374 NCCI
75889 96375 NCCI
75889 96376 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 43 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75891 01916 NCCI
75891 01924 NCCI
75891 01925 NCCI
75891 01926 NCCI
75891 35201 NCCI
75891 35206 NCCI
75891 35226 NCCI
75891 35261 NCCI
75891 35266 NCCI
75891 35286 NCCI
75891 36000 NCCI
75891 36005 NCCI
75891 36410 NCCI
75891 36500 NCCI
75891 75896 NCCI
75891 76000 NCCI
75891 76001 NCCI
75891 76942 NCCI
75891 76998 NCCI
75891 77001 NCCI
75891 77002 NCCI
75891 96360 NCCI
75891 96365 NCCI
75891 96372 NCCI
75891 96374 NCCI
75891 96375 NCCI
75891 96376 NCCI
75893 01916 NCCI
75893 01924 NCCI
75893 01925 NCCI
75893 01926 NCCI
75893 35201 NCCI
75893 35206 NCCI
75893 35226 NCCI
75893 35261 NCCI
75893 35266 NCCI
75893 35286 NCCI
75893 36000 NCCI
75893 36410 NCCI
75893 75810 NCCI
75893 75820 NCCI
75893 75822 NCCI
75893 75825 NCCI
75893 75827 NCCI
75893 75831 NCCI
75893 75833 NCCI
75893 75840 NCCI
Comprehensive ComponentCode Code Source
75893 75842 NCCI
75893 75860 NCCI
75893 75870 NCCI
75893 75872 NCCI
75893 75880 NCCI
75893 75885 NCCI
75893 75887 NCCI
75893 75889 NCCI
75893 75891 NCCI
75893 76000 NCCI
75893 76001 NCCI
75893 76942 NCCI
75893 76998 NCCI
75893 77001 NCCI
75893 77002 NCCI
75893 96360 NCCI
75893 96365 NCCI
75893 96372 NCCI
75893 96374 NCCI
75893 96375 NCCI
75893 96376 NCCI
75894 01916 NCCI
75894 01924 NCCI
75894 01925 NCCI
75894 01926 NCCI
75894 01930 NCCI
75894 01931 NCCI
75894 01932 NCCI
75894 01933 NCCI
75894 35201 NCCI
75894 35206 NCCI
75894 35226 NCCI
75894 35261 NCCI
75894 35266 NCCI
75894 35286 NCCI
75894 36000 NCCI
75894 36005 NCCI
75894 36410 NCCI
75894 36500 NCCI
75894 36600 NCCI
75894 36620 NCCI
75894 36625 NCCI
75894 36640 NCCI
75894 75600 NCCI
75894 75605 NCCI
75894 75625 NCCI
75894 75630 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 44 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75894 75635 NCCI
75894 75658 NCCI
75894 75705 NCCI
75894 75710 NCCI
75894 75716 NCCI
75894 75726 NCCI
75894 75731 NCCI
75894 75733 NCCI
75894 75736 NCCI
75894 75741 NCCI
75894 75743 NCCI
75894 75746 NCCI
75894 75756 NCCI
75894 75774 NCCI
75894 75810 NCCI
75894 75820 NCCI
75894 75822 NCCI
75894 75825 NCCI
75894 75827 NCCI
75894 75831 NCCI
75894 75833 NCCI
75894 75840 NCCI
75894 75842 NCCI
75894 75860 NCCI
75894 75870 NCCI
75894 75872 NCCI
75894 75880 NCCI
75894 75885 NCCI
75894 75887 NCCI
75894 75889 NCCI
75894 75891 NCCI
75894 75893 NCCI
75894 75960 NCCI
75894 76000 NCCI
75894 76001 NCCI
75894 76942 NCCI
75894 76998 NCCI
75894 77001 NCCI
75894 77002 NCCI
75894 96360 NCCI
75894 96365 NCCI
75894 96372 NCCI
75894 96374 NCCI
75894 96375 NCCI
75894 96376 NCCI
75896 01916 NCCI
75896 01924 NCCI
Comprehensive ComponentCode Code Source
75896 01925 NCCI
75896 01926 NCCI
75896 01930 NCCI
75896 01931 NCCI
75896 01932 NCCI
75896 01933 NCCI
75896 35201 NCCI
75896 35206 NCCI
75896 35226 NCCI
75896 35261 NCCI
75896 35266 NCCI
75896 35286 NCCI
75896 36000 NCCI
75896 36005 NCCI
75896 36410 NCCI
75896 36500 NCCI
75896 36600 NCCI
75896 36620 NCCI
75896 36625 NCCI
75896 36640 NCCI
75896 75893 NCCI
75896 75894 NCCI
75896 76000 NCCI
75896 76001 NCCI
75896 76942 NCCI
75896 76998 NCCI
75896 77001 NCCI
75896 77002 NCCI
75896 96360 NCCI
75896 96365 NCCI
75896 96372 NCCI
75896 96374 NCCI
75896 96375 NCCI
75896 96376 NCCI
75898 01916 NCCI
75898 35201 NCCI
75898 35206 NCCI
75898 35226 NCCI
75898 35261 NCCI
75898 35266 NCCI
75898 35286 NCCI
75898 36000 NCCI
75898 36005 NCCI
75898 36410 NCCI
75898 36500 NCCI
75898 75600 NCCI
75898 75605 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 45 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75898 75625 NCCI
75898 75630 NCCI
75898 75635 NCCI
75898 75658 NCCI
75898 75705 NCCI
75898 75710 NCCI
75898 75716 NCCI
75898 75726 NCCI
75898 75731 NCCI
75898 75733 NCCI
75898 75736 NCCI
75898 75741 NCCI
75898 75743 NCCI
75898 75746 NCCI
75898 75756 NCCI
75898 75774 NCCI
75898 75791 NCCI
75898 75810 NCCI
75898 75820 NCCI
75898 75822 NCCI
75898 75825 NCCI
75898 75827 NCCI
75898 75831 NCCI
75898 75833 NCCI
75898 75840 NCCI
75898 75842 NCCI
75898 75860 NCCI
75898 75870 NCCI
75898 75872 NCCI
75898 75880 NCCI
75898 75885 NCCI
75898 75887 NCCI
75898 75889 NCCI
75898 75891 NCCI
75898 75893 NCCI
75898 76000 NCCI
75898 76001 NCCI
75898 76942 NCCI
75898 76998 NCCI
75898 77001 NCCI
75898 77002 NCCI
75898 96360 NCCI
75898 96365 NCCI
75898 96372 NCCI
75898 96374 NCCI
75898 96375 NCCI
75898 96376 NCCI
Comprehensive ComponentCode Code Source
75901 01930 NCCI
75901 01930 BCBST
75901 01932 BCBST
75901 01932 NCCI
75901 36000 NCCI
75901 36005 NCCI
75901 36410 NCCI
75901 36500 NCCI
75901 36598 NCCI
75901 75741 NCCI
75901 75743 NCCI
75901 75746 NCCI
75901 75791 NCCI
75901 75825 NCCI
75901 75827 NCCI
75901 75893 NCCI
75901 75901 BCBST
75901 76000 NCCI
75901 76001 NCCI
75901 76942 NCCI
75901 76998 NCCI
75901 77001 NCCI
75901 77002 NCCI
75901 96360 NCCI
75901 96365 NCCI
75901 96372 NCCI
75901 96375 NCCI
75901 96376 NCCI
75902 01930 NCCI
75902 01930 BCBST
75902 01932 BCBST
75902 01932 NCCI
75902 36000 NCCI
75902 36005 NCCI
75902 36410 NCCI
75902 36500 NCCI
75902 36598 NCCI
75902 75741 NCCI
75902 75743 NCCI
75902 75746 NCCI
75902 75827 NCCI
75902 75891 NCCI
75902 75893 NCCI
75902 75902 BCBST
75902 76000 NCCI
75902 76001 NCCI
75902 76942 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 46 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75902 76998 NCCI
75902 77001 NCCI
75902 77002 NCCI
75902 96360 NCCI
75902 96365 NCCI
75902 96372 NCCI
75902 96375 NCCI
75902 96376 NCCI
75945 01916 NCCI
75945 01924 NCCI
75945 01925 NCCI
75945 01926 NCCI
75945 01930 NCCI
75945 01931 NCCI
75945 01932 NCCI
75945 01933 NCCI
75945 35201 NCCI
75945 35206 NCCI
75945 35226 NCCI
75945 35261 NCCI
75945 35266 NCCI
75945 35286 NCCI
75945 36000 NCCI
75945 36005 NCCI
75945 36410 NCCI
75945 36500 NCCI
75945 75893 NCCI
75945 76000 NCCI
75945 76001 NCCI
75945 76376 NCCI
75945 76377 NCCI
75945 76942 NCCI
75945 76998 NCCI
75945 77001 NCCI
75945 77002 NCCI
75945 96360 NCCI
75945 96365 NCCI
75945 96372 NCCI
75945 96375 NCCI
75945 96376 NCCI
75946 01924 NCCI
75946 01930 NCCI
75946 01931 NCCI
75946 01932 NCCI
75946 01933 NCCI
75946 35201 NCCI
75946 35206 NCCI
Comprehensive ComponentCode Code Source
75946 35226 NCCI
75946 35261 NCCI
75946 35266 NCCI
75946 35286 NCCI
75946 36005 NCCI
75946 36500 NCCI
75946 75893 NCCI
75946 76000 NCCI
75946 76000 BCBST
75946 76001 NCCI
75946 76001 BCBST
75946 76376 NCCI
75946 76377 NCCI
75946 76942 NCCI
75946 76998 NCCI
75946 77001 NCCI
75946 77002 NCCI
75952 01916 NCCI
75952 01924 NCCI
75952 01925 NCCI
75952 01926 NCCI
75952 35201 NCCI
75952 35206 NCCI
75952 35226 NCCI
75952 35261 NCCI
75952 35266 NCCI
75952 35286 NCCI
75952 36000 NCCI
75952 36005 NCCI
75952 36120 BCBST
75952 36140 BCBST
75952 36200 BCBST
75952 36245 BCBST
75952 36246 BCBST
75952 36247 BCBST
75952 36248 BCBST
75952 36410 NCCI
75952 36500 NCCI
75952 37202 BCBST
75952 75600 NCCI
75952 75605 NCCI
75952 75625 BCBST
75952 75630 BCBST
75952 75635 NCCI
75952 75710 NCCI
75952 75716 NCCI
75952 75726 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 47 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75952 75731 NCCI
75952 75733 NCCI
75952 75736 BCBST
75952 75774 NCCI
75952 75893 NCCI
75952 75952 BCBST
75952 75960 NCCI
75952 76000 BCBST
75952 76001 BCBST
75952 76120 NCCI
75952 76125 NCCI
75952 76942 BCBST
75952 76998 NCCI
75952 77001 NCCI
75952 77002 NCCI
75952 77003 NCCI
75952 96360 NCCI
75952 96365 NCCI
75952 96372 NCCI
75952 96375 NCCI
75952 96376 NCCI
75952 G0275 NCCI
75952 G0278 NCCI
75953 01916 NCCI
75953 01924 NCCI
75953 01925 NCCI
75953 01926 NCCI
75953 35201 NCCI
75953 35206 NCCI
75953 35226 NCCI
75953 35261 NCCI
75953 35266 NCCI
75953 35286 NCCI
75953 36000 NCCI
75953 36005 NCCI
75953 36120 BCBST
75953 36140 BCBST
75953 36200 BCBST
75953 36245 BCBST
75953 36246 BCBST
75953 36247 BCBST
75953 36248 BCBST
75953 36410 NCCI
75953 36500 NCCI
75953 37202 BCBST
75953 75600 NCCI
75953 75605 NCCI
Comprehensive ComponentCode Code Source
75953 75625 BCBST
75953 75630 BCBST
75953 75635 NCCI
75953 75710 NCCI
75953 75716 NCCI
75953 75726 NCCI
75953 75731 NCCI
75953 75733 NCCI
75953 75736 BCBST
75953 75774 NCCI
75953 75893 NCCI
75953 75960 NCCI
75953 76000 BCBST
75953 76001 BCBST
75953 76120 NCCI
75953 76125 NCCI
75953 76942 BCBST
75953 76998 NCCI
75953 77001 NCCI
75953 77002 NCCI
75953 77003 NCCI
75953 96360 NCCI
75953 96365 NCCI
75953 96372 NCCI
75953 96375 NCCI
75953 96376 NCCI
75953 G0275 NCCI
75953 G0278 NCCI
75954 01916 BCBST
75954 01924 BCBST
75954 01925 BCBST
75954 01926 BCBST
75954 0255T NCCI
75954 35201 NCCI
75954 35206 NCCI
75954 35226 NCCI
75954 35261 NCCI
75954 36000 NCCI
75954 36005 NCCI
75954 36410 NCCI
75954 36500 NCCI
75954 75600 NCCI
75954 75605 NCCI
75954 75625 NCCI
75954 75635 NCCI
75954 75710 NCCI
75954 75716 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 48 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75954 75726 NCCI
75954 75736 NCCI
75954 75774 NCCI
75954 75893 NCCI
75954 75960 NCCI
75954 76000 NCCI
75954 76001 NCCI
75954 76120 NCCI
75954 76125 NCCI
75954 76942 NCCI
75954 76998 NCCI
75954 77001 NCCI
75954 77002 NCCI
75954 96360 NCCI
75954 96365 NCCI
75954 96372 NCCI
75954 96375 NCCI
75954 96376 NCCI
75956 01916 NCCI
75956 01924 NCCI
75956 01926 NCCI
75956 36000 NCCI
75956 36005 NCCI
75956 36410 NCCI
75956 36500 NCCI
75956 75600 NCCI
75956 75605 NCCI
75956 75893 NCCI
75956 75957 NCCI
75956 75959 NCCI
75956 75960 NCCI
75956 76000 NCCI
75956 76001 NCCI
75956 76120 NCCI
75956 76125 NCCI
75956 76942 NCCI
75956 76998 NCCI
75956 77001 NCCI
75956 77002 NCCI
75956 96360 NCCI
75956 96365 NCCI
75956 96372 NCCI
75956 96375 NCCI
75956 96376 NCCI
75957 01916 NCCI
75957 01924 NCCI
75957 01926 NCCI
Comprehensive ComponentCode Code Source
75957 36000 NCCI
75957 36005 NCCI
75957 36410 NCCI
75957 36500 NCCI
75957 75600 NCCI
75957 75605 NCCI
75957 75893 NCCI
75957 75959 NCCI
75957 75960 NCCI
75957 76000 NCCI
75957 76001 NCCI
75957 76120 NCCI
75957 76125 NCCI
75957 76942 NCCI
75957 76998 NCCI
75957 77001 NCCI
75957 77002 NCCI
75957 96360 NCCI
75957 96365 NCCI
75957 96372 NCCI
75957 96375 NCCI
75957 96376 NCCI
75958 01916 NCCI
75958 01924 NCCI
75958 01926 NCCI
75958 36000 NCCI
75958 36005 NCCI
75958 36410 NCCI
75958 36500 NCCI
75958 75600 NCCI
75958 75605 NCCI
75958 75893 NCCI
75958 75960 NCCI
75958 76000 NCCI
75958 76001 NCCI
75958 76120 NCCI
75958 76125 NCCI
75958 76942 NCCI
75958 76998 NCCI
75958 77001 NCCI
75958 77002 NCCI
75958 96360 NCCI
75958 96365 NCCI
75958 96372 NCCI
75958 96375 NCCI
75958 96376 NCCI
75959 01916 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 49 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75959 01924 NCCI
75959 01926 NCCI
75959 36000 NCCI
75959 36005 NCCI
75959 36410 NCCI
75959 36500 NCCI
75959 75600 NCCI
75959 75605 NCCI
75959 75893 NCCI
75959 75960 NCCI
75959 76000 NCCI
75959 76001 NCCI
75959 76120 NCCI
75959 76125 NCCI
75959 76942 NCCI
75959 76998 NCCI
75959 77001 NCCI
75959 77002 NCCI
75959 96360 NCCI
75959 96365 NCCI
75959 96372 NCCI
75959 96375 NCCI
75959 96376 NCCI
75960 01916 NCCI
75960 01924 NCCI
75960 01925 NCCI
75960 01926 NCCI
75960 35201 NCCI
75960 35206 NCCI
75960 35226 NCCI
75960 35261 NCCI
75960 35266 NCCI
75960 35286 NCCI
75960 36000 NCCI
75960 36005 NCCI
75960 36410 NCCI
75960 36500 NCCI
75960 37202 NCCI
75960 75600 NCCI
75960 75605 NCCI
75960 75625 NCCI
75960 75630 NCCI
75960 75635 NCCI
75960 75658 NCCI
75960 75705 NCCI
75960 75710 NCCI
75960 75716 NCCI
Comprehensive ComponentCode Code Source
75960 75726 NCCI
75960 75731 NCCI
75960 75733 NCCI
75960 75736 NCCI
75960 75741 NCCI
75960 75743 NCCI
75960 75746 NCCI
75960 75756 NCCI
75960 75774 NCCI
75960 75791 NCCI
75960 75810 NCCI
75960 75820 NCCI
75960 75822 NCCI
75960 75825 NCCI
75960 75827 NCCI
75960 75831 NCCI
75960 75833 NCCI
75960 75840 NCCI
75960 75842 NCCI
75960 75860 NCCI
75960 75870 NCCI
75960 75872 NCCI
75960 75880 NCCI
75960 75885 NCCI
75960 75887 NCCI
75960 75889 NCCI
75960 75891 NCCI
75960 75893 NCCI
75960 76000 NCCI
75960 76001 NCCI
75960 76942 NCCI
75960 76998 NCCI
75960 77001 NCCI
75960 77002 NCCI
75960 96360 NCCI
75960 96365 NCCI
75960 96372 NCCI
75960 96375 NCCI
75960 96376 NCCI
75962 01916 NCCI
75962 01924 NCCI
75962 01925 NCCI
75962 01926 NCCI
75962 35201 NCCI
75962 35206 NCCI
75962 35226 NCCI
75962 35261 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 50 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75962 35266 NCCI
75962 35286 NCCI
75962 36000 NCCI
75962 36005 NCCI
75962 36410 NCCI
75962 36500 NCCI
75962 37202 NCCI
75962 75600 NCCI
75962 75605 NCCI
75962 75625 NCCI
75962 75630 NCCI
75962 75635 NCCI
75962 75658 NCCI
75962 75705 NCCI
75962 75710 NCCI
75962 75716 NCCI
75962 75756 NCCI
75962 75791 NCCI
75962 75893 NCCI
75962 75962 CPT
75962 76000 NCCI
75962 76001 NCCI
75962 76942 NCCI
75962 76998 NCCI
75962 77001 NCCI
75962 77002 NCCI
75962 96360 NCCI
75962 96365 NCCI
75962 96372 NCCI
75962 96375 NCCI
75962 96376 NCCI
75964 01924 NCCI
75964 01925 NCCI
75964 01926 NCCI
75964 35201 NCCI
75964 35206 NCCI
75964 35226 NCCI
75964 35261 NCCI
75964 35266 NCCI
75964 35286 NCCI
75964 36005 NCCI
75964 36500 NCCI
75964 37202 NCCI
75964 75893 NCCI
75964 76000 NCCI
75964 76001 NCCI
75964 76942 NCCI
Comprehensive ComponentCode Code Source
75964 76998 NCCI
75964 77001 NCCI
75964 77002 NCCI
75966 01916 NCCI
75966 01924 NCCI
75966 01925 NCCI
75966 01926 NCCI
75966 35201 NCCI
75966 35206 NCCI
75966 35226 NCCI
75966 35261 NCCI
75966 35266 NCCI
75966 35286 NCCI
75966 36000 NCCI
75966 36005 NCCI
75966 36410 NCCI
75966 36500 NCCI
75966 37202 NCCI
75966 75726 NCCI
75966 75731 NCCI
75966 75733 NCCI
75966 75736 NCCI
75966 75893 NCCI
75966 75966 CPT
75966 76000 NCCI
75966 76001 NCCI
75966 76942 NCCI
75966 76998 NCCI
75966 77001 NCCI
75966 77002 NCCI
75966 96360 NCCI
75966 96365 NCCI
75966 96372 NCCI
75966 96375 NCCI
75966 96376 NCCI
75968 01924 NCCI
75968 35201 NCCI
75968 35206 NCCI
75968 35226 NCCI
75968 35261 NCCI
75968 35266 NCCI
75968 35286 NCCI
75968 36005 NCCI
75968 36500 NCCI
75968 37202 NCCI
75968 75893 NCCI
75968 76000 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 51 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75968 76001 NCCI
75968 76942 NCCI
75968 76998 NCCI
75968 77001 NCCI
75968 77002 NCCI
75970 01916 NCCI
75970 01924 NCCI
75970 01925 NCCI
75970 01926 NCCI
75970 01930 NCCI
75970 01931 NCCI
75970 01932 NCCI
75970 01933 NCCI
75970 35201 NCCI
75970 35206 NCCI
75970 35226 NCCI
75970 35261 NCCI
75970 35266 NCCI
75970 35286 NCCI
75970 36000 NCCI
75970 36005 NCCI
75970 36410 NCCI
75970 36500 NCCI
75970 75600 NCCI
75970 75605 NCCI
75970 75625 NCCI
75970 75630 NCCI
75970 75635 NCCI
75970 75658 NCCI
75970 75705 NCCI
75970 75710 NCCI
75970 75716 NCCI
75970 75726 NCCI
75970 75731 NCCI
75970 75733 NCCI
75970 75736 NCCI
75970 75741 NCCI
75970 75743 NCCI
75970 75746 NCCI
75970 75756 NCCI
75970 75774 NCCI
75970 75791 NCCI
75970 75810 NCCI
75970 75820 NCCI
75970 75822 NCCI
75970 75825 NCCI
75970 75827 NCCI
Comprehensive ComponentCode Code Source
75970 75831 NCCI
75970 75833 NCCI
75970 75840 NCCI
75970 75842 NCCI
75970 75860 NCCI
75970 75870 NCCI
75970 75872 NCCI
75970 75880 NCCI
75970 75885 NCCI
75970 75887 NCCI
75970 75889 NCCI
75970 75891 NCCI
75970 75893 NCCI
75970 76000 NCCI
75970 76001 NCCI
75970 76942 NCCI
75970 76998 NCCI
75970 77001 NCCI
75970 77002 NCCI
75970 96360 NCCI
75970 96365 NCCI
75970 96372 NCCI
75970 96375 NCCI
75970 96376 NCCI
75978 01916 NCCI
75978 01924 NCCI
75978 01925 NCCI
75978 01926 NCCI
75978 01930 NCCI
75978 01931 NCCI
75978 01932 NCCI
75978 01933 NCCI
75978 35201 NCCI
75978 35206 NCCI
75978 35226 NCCI
75978 35261 NCCI
75978 35266 NCCI
75978 35286 NCCI
75978 36000 NCCI
75978 36005 NCCI
75978 36410 NCCI
75978 36500 NCCI
75978 37202 NCCI
75978 75810 NCCI
75978 75820 NCCI
75978 75822 NCCI
75978 75825 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 52 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
75978 75827 NCCI
75978 75831 NCCI
75978 75833 NCCI
75978 75840 NCCI
75978 75842 NCCI
75978 75860 NCCI
75978 75870 NCCI
75978 75872 NCCI
75978 75880 NCCI
75978 75885 NCCI
75978 75887 NCCI
75978 75889 NCCI
75978 75891 NCCI
75978 75893 NCCI
75978 76000 NCCI
75978 76001 NCCI
75978 76942 NCCI
75978 76998 NCCI
75978 77001 NCCI
75978 77002 NCCI
75978 96360 NCCI
75978 96365 NCCI
75978 96372 NCCI
75978 96375 NCCI
75978 96376 NCCI
75980 01916 NCCI
75980 01924 NCCI
75980 01925 NCCI
75980 01926 NCCI
75980 36000 NCCI
75980 36005 NCCI
75980 36406 NCCI
75980 36410 NCCI
75980 36500 NCCI
75980 74320 NCCI
75980 75893 NCCI
75980 75982 NCCI
75980 75989 NCCI
75980 76000 NCCI
75980 76001 NCCI
75980 76942 NCCI
75980 77001 NCCI
75980 77002 NCCI
75980 96372 NCCI
75980 96374 NCCI
75980 96375 NCCI
75980 96376 NCCI
Comprehensive ComponentCode Code Source
75982 01916 NCCI
75982 01924 NCCI
75982 01925 NCCI
75982 01926 NCCI
75982 36005 NCCI
75982 36500 NCCI
75982 74320 NCCI
75982 74320 BCBST
75982 75893 NCCI
75982 75989 NCCI
75982 76000 NCCI
75982 76001 NCCI
75982 76942 NCCI
75982 77001 NCCI
75982 77002 NCCI
75984 01916 NCCI
75984 01924 NCCI
75984 01925 NCCI
75984 01926 NCCI
75984 36005 NCCI
75984 36500 NCCI
75984 75893 NCCI
75984 75982 NCCI
75984 76000 NCCI
75984 76001 NCCI
75984 77001 NCCI
75984 77002 NCCI
75984 96372 NCCI
75984 96374 NCCI
75984 96375 NCCI
75984 96376 NCCI
75984 J1644 NCCI
75989 36005 NCCI
75989 36500 NCCI
75989 75893 NCCI
75989 76000 NCCI
75989 76001 NCCI
75989 76376 NCCI
75989 76377 NCCI
75989 76942 NCCI
75989 76998 NCCI
75989 77001 NCCI
75989 77002 NCCI
75989 77003 NCCI
75989 77012 NCCI
75989 77021 NCCI
76000 36000 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 53 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
76000 36011 NCCI
76000 36410 NCCI
76000 36425 NCCI
76000 76125 NCCI
76000 76942 NCCI
76001 36000 NCCI
76001 36011 NCCI
76001 36410 NCCI
76001 36425 NCCI
76001 76000 NCCI
76010 71010 NCCI
76010 71015 NCCI
76010 71020 NCCI
76010 71021 NCCI
76010 71022 NCCI
76010 71023 NCCI
76010 71030 NCCI
76010 71034 NCCI
76010 71035 NCCI
76010 74000 NCCI
76080 76000 NCCI
76080 76001 NCCI
76080 77001 NCCI
76080 77002 NCCI
76098 76098 BCBST
76100 74400 NCCI
76100 74410 NCCI
76100 74415 NCCI
76100 74420 NCCI
76100 74425 NCCI
76100 76000 NCCI
76100 76001 NCCI
76100 76100 BCBST
76100 77001 NCCI
76101 76000 NCCI
76101 76001 NCCI
76101 76101 CPT
76101 77001 NCCI
76102 76000 NCCI
76102 76001 NCCI
76102 76101 NCCI
76102 77001 NCCI
76120 76000 NCCI
76120 76001 NCCI
76120 77001 NCCI
76120 77002 NCCI
76120 77003 NCCI
Comprehensive ComponentCode Code Source
76125 76001 NCCI
76125 76120 NCCI
76140 76140 BCBST
76376 0159T NCCI
76377 0159T NCCI
76377 76376 NCCI
76506 76511 NCCI
76506 76512 NCCI
76506 76513 NCCI
76506 76998 NCCI
76510 76511 NCCI
76510 76512 NCCI
76510 76516 NCCI
76510 76519 NCCI
76511 76519 NCCI
76511 76998 NCCI
76511 J2001 NCCI
76512 76511 NCCI
76512 76529 NCCI
76512 76998 NCCI
76512 J2001 NCCI
76513 69990 NCCI
76513 76512 NCCI
76513 76529 NCCI
76513 76998 NCCI
76513 92132 NCCI
76513 92504 NCCI
76513 J2001 NCCI
76516 76511 NCCI
76516 76512 NCCI
76516 76513 NCCI
76516 76998 NCCI
76519 76513 NCCI
76519 76516 NCCI
76519 76998 NCCI
76519 99211 NCCI
76519 99211 NCCI
76529 76998 NCCI
76529 J2001 NCCI
76536 76998 NCCI
76536 93880 NCCI
76604 76998 NCCI
76645 76998 NCCI
76700 51701 NCCI
76700 51702 NCCI
76700 76705 NCCI
76700 76998 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 54 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
76705 51701 NCCI
76705 51702 NCCI
76705 76998 NCCI
76770 51701 NCCI
76770 51702 NCCI
76770 51798 NCCI
76770 76775 NCCI
76770 76998 NCCI
76770 G0389 NCCI
76775 51701 NCCI
76775 51702 NCCI
76775 76857 NCCI
76775 76998 NCCI
76775 G0389 NCCI
76776 76775 NCCI
76776 76998 NCCI
76800 01935 NCCI
76800 01936 NCCI
76800 76998 NCCI
76801 76801 BCBST
76801 76805 NCCI
76801 76810 NCCI
76801 76812 NCCI
76801 76815 NCCI
76801 76816 NCCI
76801 76830 NCCI
76801 76998 NCCI
76802 76998 NCCI
76805 51701 NCCI
76805 51702 NCCI
76805 76802 NCCI
76805 76812 NCCI
76805 76815 NCCI
76805 76816 NCCI
76805 76830 NCCI
76805 76831 NCCI
76805 76856 NCCI
76805 76857 NCCI
76805 76998 NCCI
76810 51701 NCCI
76810 51702 NCCI
76810 76815 NCCI
76810 76998 NCCI
76811 51701 NCCI
76811 51702 NCCI
76811 76801 NCCI
76811 76802 CPT
Comprehensive ComponentCode Code Source
76811 76805 NCCI
76811 76810 CPT
76811 76811 CPT
76811 76815 NCCI
76811 76816 NCCI
76811 76830 NCCI
76811 76831 NCCI
76811 76856 NCCI
76811 76857 NCCI
76811 76941 Reversed NCCI
76811 76998 NCCI
76812 51701 NCCI
76812 51702 NCCI
76812 76998 NCCI
76813 51701 NCCI
76813 51702 NCCI
76813 76830 NCCI
76813 76857 NCCI
76813 76998 NCCI
76815 51701 NCCI
76815 51702 NCCI
76815 76857 NCCI
76815 76998 NCCI
76816 51701 NCCI
76816 51702 NCCI
76816 76810 NCCI
76816 76815 NCCI
76816 76857 NCCI
76816 76998 NCCI
76817 51701 NCCI
76817 51702 NCCI
76817 76817 BCBST
76817 76830 NCCI
76817 76831 NCCI
76817 76856 NCCI
76817 76857 NCCI
76817 76941 Reversed NCCI
76817 76998 NCCI
76818 51701 NCCI
76818 51702 NCCI
76818 59025 NCCI
76818 76376 NCCI
76818 76377 NCCI
76818 76819 NCCI
76818 76998 NCCI
76819 51701 NCCI
76819 51702 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 55 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
76819 59020 NCCI
76819 59025 NCCI
76819 76376 NCCI
76819 76377 NCCI
76819 76998 NCCI
76820 76828 NCCI
76821 76376 NCCI
76821 76377 NCCI
76821 76828 NCCI
76825 51701 NCCI
76825 51702 NCCI
76825 76998 NCCI
76826 51701 NCCI
76826 51702 NCCI
76826 76825 NCCI
76826 76998 NCCI
76827 51701 NCCI
76827 51702 NCCI
76827 76376 NCCI
76827 76377 NCCI
76827 76998 NCCI
76828 51701 NCCI
76828 51702 NCCI
76828 76376 NCCI
76828 76377 NCCI
76828 76827 NCCI
76828 76998 NCCI
76830 51701 NCCI
76830 51702 NCCI
76830 76815 NCCI
76830 76816 NCCI
76830 76998 NCCI
76831 51701 NCCI
76831 51702 NCCI
76831 76801 NCCI
76831 76813 NCCI
76831 76815 NCCI
76831 76816 NCCI
76831 76830 NCCI
76831 76998 NCCI
76856 51701 NCCI
76856 51702 NCCI
76856 51798 NCCI
76856 76801 Reversed NCCI
76856 76813 NCCI
76856 76815 NCCI
76856 76816 NCCI
Comprehensive ComponentCode Code Source
76856 76857 NCCI
76856 76941 NCCI
76856 76998 NCCI
76856 93976 NCCI
76856 93980 NCCI
76857 51701 NCCI
76857 51702 NCCI
76857 51798 NCCI
76857 76801 Reversed NCCI
76857 76810 NCCI
76857 76941 NCCI
76857 76998 NCCI
76857 93975 NCCI
76857 93976 NCCI
76857 93978 NCCI
76857 93979 NCCI
76857 93980 NCCI
76857 93981 NCCI
76870 76998 NCCI
76872 0226T NCCI
76872 0288T NCCI
76872 46600 NCCI
76872 51701 NCCI
76872 51702 NCCI
76872 51798 NCCI
76872 76873 NCCI
76872 76998 NCCI
76873 0226T NCCI
76873 0288T NCCI
76873 46600 NCCI
76873 51701 NCCI
76873 51702 NCCI
76873 51798 NCCI
76873 55873 NCCI
76873 76873 BCBST
76873 76942 NCCI
76873 76998 NCCI
76881 76882 NCCI
76881 76998 NCCI
76882 76998 NCCI
76885 76376 NCCI
76885 76377 NCCI
76885 76886 NCCI
76885 76998 NCCI
76886 76376 NCCI
76886 76377 NCCI
76886 76998 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 56 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
76930 76000 NCCI
76930 76001 NCCI
76930 76376 NCCI
76930 76377 NCCI
76930 76942 NCCI
76930 76998 NCCI
76930 77001 NCCI
76930 77002 NCCI
76930 77012 NCCI
76930 77021 NCCI
76932 76000 NCCI
76932 76001 NCCI
76932 76376 NCCI
76932 76377 NCCI
76932 76942 NCCI
76932 76998 NCCI
76932 77001 NCCI
76932 77002 NCCI
76932 77012 NCCI
76932 77021 NCCI
76936 76000 NCCI
76936 76001 NCCI
76936 76376 NCCI
76936 76377 NCCI
76936 76942 NCCI
76936 76998 NCCI
76936 77001 NCCI
76936 77002 NCCI
76936 77012 NCCI
76936 77021 NCCI
76936 93922 NCCI
76936 93923 NCCI
76936 93924 NCCI
76936 93926 NCCI
76936 93930 NCCI
76936 93931 NCCI
76936 93990 NCCI
76937 76000 NCCI
76937 76001 NCCI
76937 76942 NCCI
76937 76998 NCCI
76937 77002 NCCI
76940 76942 NCCI
76940 76998 NCCI
76941 76000 NCCI
76941 76001 NCCI
76941 76801 NCCI
Comprehensive ComponentCode Code Source
76941 76802 CPT
76941 76805 NCCI
76941 76810 NCCI
76941 76812 CPT
76941 76815 NCCI
76941 76816 NCCI
76941 76825 NCCI
76941 76826 NCCI
76941 76827 NCCI
76941 76828 NCCI
76941 76830 NCCI
76941 76942 NCCI
76941 76998 NCCI
76941 77001 NCCI
76941 77002 NCCI
76941 77012 NCCI
76941 77021 NCCI
76942 01922 NCCI
76942 51798 NCCI
76942 76001 NCCI
76942 76998 NCCI
76942 77002 NCCI
76942 77003 NCCI
76942 77012 NCCI
76942 77021 NCCI
76942 77031 NCCI
76942 77032 NCCI
76945 76000 NCCI
76945 76001 NCCI
76945 76942 NCCI
76945 76946 NCCI
76945 76998 NCCI
76945 77001 NCCI
76945 77002 NCCI
76945 77012 NCCI
76945 77021 NCCI
76946 76000 NCCI
76946 76001 NCCI
76946 76942 NCCI
76946 76998 NCCI
76946 77001 NCCI
76946 77002 NCCI
76946 77012 NCCI
76946 77021 NCCI
76948 76000 NCCI
76948 76001 NCCI
76948 76942 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 57 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
76948 76945 NCCI
76948 76998 NCCI
76948 77001 NCCI
76948 77002 NCCI
76948 77012 NCCI
76948 77021 NCCI
76948 S8055 BCBST
76950 0197T NCCI
76950 55873 NCCI
76950 76000 NCCI
76950 76001 NCCI
76950 76942 NCCI
76950 76998 NCCI
76950 77001 NCCI
76950 77002 NCCI
76950 77012 NCCI
76950 77021 NCCI
76965 00860 NCCI
76965 55873 NCCI
76965 76000 NCCI
76965 76001 NCCI
76965 76872 NCCI
76965 76873 NCCI
76965 76942 NCCI
76965 76998 NCCI
76965 77001 NCCI
76965 77002 NCCI
76965 77012 NCCI
76965 77021 NCCI
76970 76965 NCCI
76970 76998 NCCI
76975 76376 NCCI
76975 76377 NCCI
76975 76942 NCCI
76975 76998 NCCI
76977 76376 NCCI
76977 76377 NCCI
76977 76998 NCCI
77001 36005 NCCI
77001 36598 NCCI
77001 71010 NCCI
77001 71020 NCCI
77001 75820 NCCI
77001 75822 NCCI
77001 75825 NCCI
77001 75827 NCCI
77001 76000 NCCI
Comprehensive ComponentCode Code Source
77001 76001 NCCI
77001 76942 NCCI
77001 76998 NCCI
77001 77002 NCCI
77002 76000 NCCI
77002 76001 NCCI
77002 76125 NCCI
77002 77003 NCCI
77002 77032 NCCI
77003 01922 NCCI
77003 01935 NCCI
77003 01936 NCCI
77003 76000 NCCI
77003 76001 NCCI
77003 76125 NCCI
77003 77032 NCCI
77011 76380 NCCI
77011 77012 NCCI
77011 77031 NCCI
77012 01922 NCCI
77012 76000 NCCI
77012 76001 NCCI
77012 76380 NCCI
77012 77001 NCCI
77012 77002 NCCI
77012 77003 NCCI
77012 77031 NCCI
77012 77032 NCCI
77013 76380 NCCI
77013 76940 NCCI
77013 77012 NCCI
77014 0197T NCCI
77014 76380 NCCI
77014 76950 NCCI
77014 77421 NCCI
77021 01922 NCCI
77021 76000 NCCI
77021 76001 NCCI
77021 77001 NCCI
77021 77002 NCCI
77021 77003 NCCI
77021 77012 NCCI
77021 77031 NCCI
77021 77032 NCCI
77022 70557 NCCI
77022 70558 NCCI
77022 70559 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 58 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77022 76940 NCCI
77022 77013 NCCI
77022 77021 NCCI
77031 61781 NCCI
77031 61782 NCCI
77031 61783 NCCI
77031 76000 NCCI
77031 76001 NCCI
77031 77001 NCCI
77031 77002 NCCI
77031 77003 NCCI
77031 77032 NCCI
77032 76000 NCCI
77032 76001 NCCI
77032 77001 NCCI
77054 77053 NCCI
77056 77055 NCCI
77056 G0206 NCCI
77058 36000 NCCI
77058 36005 NCCI
77058 36410 NCCI
77058 76000 NCCI
77058 76001 NCCI
77058 76942 NCCI
77058 76998 NCCI
77058 77001 NCCI
77058 77002 NCCI
77058 96360 NCCI
77058 96365 NCCI
77058 96372 NCCI
77058 96374 NCCI
77058 96375 NCCI
77058 96376 NCCI
77058 A9576 BCBST
77058 A9577 BCBST
77058 A9578 BCBST
77058 A9579 BCBST
77058 J1642 NCCI
77058 Q9953 BCBST
77059 36000 NCCI
77059 36005 NCCI
77059 36410 NCCI
77059 76000 NCCI
77059 76001 NCCI
77059 76942 NCCI
77059 76998 NCCI
77059 77001 NCCI
Comprehensive ComponentCode Code Source
77059 77002 NCCI
77059 77058 NCCI
77059 96360 NCCI
77059 96365 NCCI
77059 96372 NCCI
77059 96374 NCCI
77059 96375 NCCI
77059 96376 NCCI
77059 A9576 BCBST
77059 A9577 BCBST
77059 A9578 BCBST
77059 A9579 BCBST
77059 J1642 NCCI
77059 Q9953 BCBST
77073 72170 NCCI
77073 73500 NCCI
77073 73510 NCCI
77073 73520 NCCI
77073 73540 NCCI
77073 73550 NCCI
77073 73560 NCCI
77073 73562 NCCI
77073 73564 NCCI
77073 73565 NCCI
77073 73590 NCCI
77073 73592 NCCI
77073 73600 NCCI
77073 73610 NCCI
77075 70260 NCCI
77075 70355 NCCI
77075 71010 NCCI
77075 71020 NCCI
77075 71100 NCCI
77075 71110 NCCI
77075 73030 NCCI
77075 73510 NCCI
77075 73590 NCCI
77075 73620 NCCI
77075 77074 NCCI
77075 77076 NCCI
77076 77074 NCCI
77077 76000 NCCI
77077 76001 NCCI
77077 77001 NCCI
77077 77002 NCCI
77078 76380 NCCI
77078 76977 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 59 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77078 77080 NCCI
77078 77081 NCCI
77078 77082 NCCI
77078 G0130 NCCI
77080 76977 NCCI
77081 36410 NCCI
77081 76977 NCCI
77081 77080 NCCI
77081 G0130 NCCI
77084 76000 NCCI
77084 76001 NCCI
77084 76942 NCCI
77084 76998 NCCI
77084 77001 NCCI
77084 77002 NCCI
77261 11920 NCCI
77261 11921 NCCI
77261 16000 NCCI
77261 16020 NCCI
77261 16025 NCCI
77261 16030 NCCI
77261 36000 NCCI
77261 36410 NCCI
77261 36425 NCCI
77261 51701 NCCI
77261 51702 NCCI
77261 51703 NCCI
77261 77261 CPT
77261 77336 NCCI
77261 90832 NCCI
77261 90833 NCCI
77261 90834 NCCI
77261 90836 NCCI
77261 90837 NCCI
77261 90838 NCCI
77261 90839 NCCI
77261 90846 NCCI
77261 90847 NCCI
77261 96360 NCCI
77261 96361 NCCI
77261 96365 NCCI
77261 96366 NCCI
77261 96367 NCCI
77261 96368 NCCI
77261 97802 NCCI
77261 97803 NCCI
77261 97804 NCCI
Comprehensive ComponentCode Code Source
77261 99143 NCCI
77261 99144 NCCI
77261 99145 NCCI
77261 99201 NCCI
77261 99202 NCCI
77261 99203 NCCI
77261 99204 NCCI
77261 99205 NCCI
77261 99211 NCCI
77261 99212 NCCI
77261 99213 NCCI
77261 99214 NCCI
77261 99215 NCCI
77261 99217 NCCI
77261 99218 NCCI
77261 99219 NCCI
77261 99220 NCCI
77261 99221 NCCI
77261 99222 NCCI
77261 99223 NCCI
77261 99224 NCCI
77261 99225 NCCI
77261 99226 NCCI
77261 99231 NCCI
77261 99232 NCCI
77261 99233 NCCI
77261 99234 NCCI
77261 99235 NCCI
77261 99236 NCCI
77261 99238 NCCI
77261 99239 NCCI
77261 99281 NCCI
77261 99282 NCCI
77261 99283 NCCI
77261 99284 NCCI
77261 99285 NCCI
77261 99291 NCCI
77261 99292 NCCI
77261 99304 NCCI
77261 99305 NCCI
77261 99306 NCCI
77261 99307 NCCI
77261 99308 NCCI
77261 99309 NCCI
77261 99310 NCCI
77261 99315 NCCI
77261 99316 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 60 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77261 99318 NCCI
77261 99324 NCCI
77261 99325 NCCI
77261 99326 NCCI
77261 99327 NCCI
77261 99328 NCCI
77261 99334 NCCI
77261 99335 NCCI
77261 99336 NCCI
77261 99337 NCCI
77261 99341 NCCI
77261 99342 NCCI
77261 99343 NCCI
77261 99344 NCCI
77261 99345 NCCI
77261 99347 NCCI
77261 99348 NCCI
77261 99349 NCCI
77261 99350 NCCI
77261 99354 NCCI
77261 99355 NCCI
77261 99356 NCCI
77261 99357 NCCI
77261 99360 NCCI
77261 99455 NCCI
77261 99456 NCCI
77261 99460 NCCI
77261 99461 NCCI
77261 99462 NCCI
77261 99463 NCCI
77261 99464 NCCI
77261 99465 NCCI
77261 99466 NCCI
77261 99467 NCCI
77261 99468 NCCI
77261 99469 NCCI
77261 99471 NCCI
77261 99472 NCCI
77261 99475 NCCI
77261 99476 NCCI
77261 99477 NCCI
77261 99478 NCCI
77261 99479 NCCI
77261 99480 NCCI
77261 99485 NCCI
77261 G0459 NCCI
77261 M0064 NCCI
Comprehensive ComponentCode Code Source
77262 11920 NCCI
77262 11921 NCCI
77262 16000 NCCI
77262 16020 NCCI
77262 16025 NCCI
77262 16030 NCCI
77262 36000 NCCI
77262 36410 NCCI
77262 36425 NCCI
77262 51701 NCCI
77262 51702 NCCI
77262 51703 NCCI
77262 77261 NCCI
77262 77262 CPT
77262 77336 NCCI
77262 90832 NCCI
77262 90833 NCCI
77262 90834 NCCI
77262 90836 NCCI
77262 90837 NCCI
77262 90838 NCCI
77262 90839 NCCI
77262 90846 NCCI
77262 90847 NCCI
77262 96360 NCCI
77262 96361 NCCI
77262 96365 NCCI
77262 96366 NCCI
77262 96367 NCCI
77262 96368 NCCI
77262 97802 NCCI
77262 97803 NCCI
77262 97804 NCCI
77262 99143 NCCI
77262 99144 NCCI
77262 99145 NCCI
77262 99201 NCCI
77262 99202 NCCI
77262 99203 NCCI
77262 99204 NCCI
77262 99205 NCCI
77262 99211 NCCI
77262 99212 NCCI
77262 99213 NCCI
77262 99214 NCCI
77262 99215 NCCI
77262 99217 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 61 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77262 99218 NCCI
77262 99219 NCCI
77262 99220 NCCI
77262 99221 NCCI
77262 99222 NCCI
77262 99223 NCCI
77262 99224 NCCI
77262 99225 NCCI
77262 99226 NCCI
77262 99231 NCCI
77262 99232 NCCI
77262 99233 NCCI
77262 99234 NCCI
77262 99235 NCCI
77262 99236 NCCI
77262 99238 NCCI
77262 99239 NCCI
77262 99281 NCCI
77262 99282 NCCI
77262 99283 NCCI
77262 99284 NCCI
77262 99285 NCCI
77262 99291 NCCI
77262 99292 NCCI
77262 99304 NCCI
77262 99305 NCCI
77262 99306 NCCI
77262 99307 NCCI
77262 99308 NCCI
77262 99309 NCCI
77262 99310 NCCI
77262 99315 NCCI
77262 99316 NCCI
77262 99318 NCCI
77262 99324 NCCI
77262 99325 NCCI
77262 99326 NCCI
77262 99327 NCCI
77262 99328 NCCI
77262 99334 NCCI
77262 99335 NCCI
77262 99336 NCCI
77262 99337 NCCI
77262 99341 NCCI
77262 99342 NCCI
77262 99343 NCCI
77262 99344 NCCI
Comprehensive ComponentCode Code Source
77262 99345 NCCI
77262 99347 NCCI
77262 99348 NCCI
77262 99349 NCCI
77262 99350 NCCI
77262 99354 NCCI
77262 99355 NCCI
77262 99356 NCCI
77262 99357 NCCI
77262 99360 NCCI
77262 99455 NCCI
77262 99456 NCCI
77262 99460 NCCI
77262 99461 NCCI
77262 99462 NCCI
77262 99463 NCCI
77262 99464 NCCI
77262 99465 NCCI
77262 99466 NCCI
77262 99467 NCCI
77262 99468 NCCI
77262 99469 NCCI
77262 99471 NCCI
77262 99472 NCCI
77262 99475 NCCI
77262 99476 NCCI
77262 99477 NCCI
77262 99478 NCCI
77262 99479 NCCI
77262 99480 NCCI
77262 99485 NCCI
77262 G0459 NCCI
77262 M0064 NCCI
77263 11920 NCCI
77263 11921 NCCI
77263 16000 NCCI
77263 16020 NCCI
77263 16025 NCCI
77263 16030 NCCI
77263 36000 NCCI
77263 36410 NCCI
77263 36425 NCCI
77263 51701 NCCI
77263 51702 NCCI
77263 51703 NCCI
77263 77261 NCCI
77263 77262 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 62 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77263 77263 CPT
77263 77336 NCCI
77263 90832 NCCI
77263 90833 NCCI
77263 90834 NCCI
77263 90836 NCCI
77263 90837 NCCI
77263 90838 NCCI
77263 90839 NCCI
77263 90846 NCCI
77263 90847 NCCI
77263 96360 NCCI
77263 96361 NCCI
77263 96365 NCCI
77263 96366 NCCI
77263 96367 NCCI
77263 96368 NCCI
77263 97802 NCCI
77263 97803 NCCI
77263 97804 NCCI
77263 99143 NCCI
77263 99144 NCCI
77263 99145 NCCI
77263 99201 NCCI
77263 99202 NCCI
77263 99203 NCCI
77263 99204 NCCI
77263 99205 NCCI
77263 99211 NCCI
77263 99212 NCCI
77263 99213 NCCI
77263 99214 NCCI
77263 99215 NCCI
77263 99217 NCCI
77263 99218 NCCI
77263 99219 NCCI
77263 99220 NCCI
77263 99221 NCCI
77263 99222 NCCI
77263 99223 NCCI
77263 99224 NCCI
77263 99225 NCCI
77263 99226 NCCI
77263 99231 NCCI
77263 99232 NCCI
77263 99233 NCCI
77263 99234 NCCI
Comprehensive ComponentCode Code Source
77263 99235 NCCI
77263 99236 NCCI
77263 99238 NCCI
77263 99239 NCCI
77263 99281 NCCI
77263 99282 NCCI
77263 99283 NCCI
77263 99284 NCCI
77263 99285 NCCI
77263 99291 NCCI
77263 99292 NCCI
77263 99304 NCCI
77263 99305 NCCI
77263 99306 NCCI
77263 99307 NCCI
77263 99308 NCCI
77263 99309 NCCI
77263 99310 NCCI
77263 99315 NCCI
77263 99316 NCCI
77263 99318 NCCI
77263 99324 NCCI
77263 99325 NCCI
77263 99326 NCCI
77263 99327 NCCI
77263 99328 NCCI
77263 99334 NCCI
77263 99335 NCCI
77263 99336 NCCI
77263 99337 NCCI
77263 99341 NCCI
77263 99342 NCCI
77263 99343 NCCI
77263 99344 NCCI
77263 99345 NCCI
77263 99347 NCCI
77263 99348 NCCI
77263 99349 NCCI
77263 99350 NCCI
77263 99354 NCCI
77263 99355 NCCI
77263 99356 NCCI
77263 99357 NCCI
77263 99360 NCCI
77263 99455 NCCI
77263 99456 NCCI
77263 99460 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 63 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77263 99461 NCCI
77263 99462 NCCI
77263 99463 NCCI
77263 99464 NCCI
77263 99465 NCCI
77263 99466 NCCI
77263 99467 NCCI
77263 99468 NCCI
77263 99469 NCCI
77263 99471 NCCI
77263 99472 NCCI
77263 99475 NCCI
77263 99476 NCCI
77263 99477 NCCI
77263 99478 NCCI
77263 99479 NCCI
77263 99480 NCCI
77263 99485 NCCI
77263 G0459 NCCI
77263 M0064 NCCI
77280 11920 NCCI
77280 11921 NCCI
77280 16000 NCCI
77280 16020 NCCI
77280 16025 NCCI
77280 16030 NCCI
77280 36000 NCCI
77280 36410 NCCI
77280 36425 NCCI
77280 51701 NCCI
77280 51702 NCCI
77280 51703 NCCI
77280 76000 NCCI
77280 76001 NCCI
77280 76376 NCCI
77280 76377 NCCI
77280 77280 CPT
77280 77336 NCCI
77280 90832 NCCI
77280 90833 NCCI
77280 90834 NCCI
77280 90836 NCCI
77280 90837 NCCI
77280 90838 NCCI
77280 90839 NCCI
77280 90846 NCCI
77280 90847 NCCI
Comprehensive ComponentCode Code Source
77280 96360 NCCI
77280 96361 NCCI
77280 96365 NCCI
77280 96366 NCCI
77280 96367 NCCI
77280 96368 NCCI
77280 97802 NCCI
77280 97803 NCCI
77280 97804 NCCI
77280 99143 NCCI
77280 99144 NCCI
77280 99145 NCCI
77280 99201 NCCI
77280 99202 NCCI
77280 99203 NCCI
77280 99204 NCCI
77280 99205 NCCI
77280 99211 NCCI
77280 99212 NCCI
77280 99213 NCCI
77280 99214 NCCI
77280 99215 NCCI
77280 99217 NCCI
77280 99218 NCCI
77280 99219 NCCI
77280 99220 NCCI
77280 99221 NCCI
77280 99222 NCCI
77280 99223 NCCI
77280 99224 NCCI
77280 99225 NCCI
77280 99226 NCCI
77280 99231 NCCI
77280 99232 NCCI
77280 99233 NCCI
77280 99234 NCCI
77280 99235 NCCI
77280 99236 NCCI
77280 99238 NCCI
77280 99239 NCCI
77280 99281 NCCI
77280 99282 NCCI
77280 99283 NCCI
77280 99284 NCCI
77280 99285 NCCI
77280 99291 NCCI
77280 99292 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 64 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77280 99304 NCCI
77280 99305 NCCI
77280 99306 NCCI
77280 99307 NCCI
77280 99308 NCCI
77280 99309 NCCI
77280 99310 NCCI
77280 99315 NCCI
77280 99316 NCCI
77280 99318 NCCI
77280 99324 NCCI
77280 99325 NCCI
77280 99326 NCCI
77280 99327 NCCI
77280 99328 NCCI
77280 99334 NCCI
77280 99335 NCCI
77280 99336 NCCI
77280 99337 NCCI
77280 99341 NCCI
77280 99342 NCCI
77280 99343 NCCI
77280 99344 NCCI
77280 99345 NCCI
77280 99347 NCCI
77280 99348 NCCI
77280 99349 NCCI
77280 99350 NCCI
77280 99354 NCCI
77280 99355 NCCI
77280 99356 NCCI
77280 99357 NCCI
77280 99360 NCCI
77280 99455 NCCI
77280 99456 NCCI
77280 99460 NCCI
77280 99461 NCCI
77280 99462 NCCI
77280 99463 NCCI
77280 99464 NCCI
77280 99465 NCCI
77280 99466 NCCI
77280 99467 NCCI
77280 99468 NCCI
77280 99469 NCCI
77280 99471 NCCI
77280 99472 NCCI
Comprehensive ComponentCode Code Source
77280 99475 NCCI
77280 99476 NCCI
77280 99477 NCCI
77280 99478 NCCI
77280 99479 NCCI
77280 99480 NCCI
77280 99485 NCCI
77280 G0459 NCCI
77280 M0064 NCCI
77285 11920 NCCI
77285 11921 NCCI
77285 16000 NCCI
77285 16020 NCCI
77285 16025 NCCI
77285 16030 NCCI
77285 36000 NCCI
77285 36410 NCCI
77285 36425 NCCI
77285 51701 NCCI
77285 51702 NCCI
77285 51703 NCCI
77285 76000 NCCI
77285 76001 NCCI
77285 76376 NCCI
77285 76377 NCCI
77285 77280 NCCI
77285 77285 CPT
77285 77336 NCCI
77285 90832 NCCI
77285 90833 NCCI
77285 90834 NCCI
77285 90836 NCCI
77285 90837 NCCI
77285 90838 NCCI
77285 90839 NCCI
77285 90846 NCCI
77285 90847 NCCI
77285 96360 NCCI
77285 96361 NCCI
77285 96365 NCCI
77285 96366 NCCI
77285 96367 NCCI
77285 96368 NCCI
77285 97802 NCCI
77285 97803 NCCI
77285 97804 NCCI
77285 99143 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 65 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77285 99144 NCCI
77285 99145 NCCI
77285 99201 NCCI
77285 99202 NCCI
77285 99203 NCCI
77285 99204 NCCI
77285 99205 NCCI
77285 99211 NCCI
77285 99212 NCCI
77285 99213 NCCI
77285 99214 NCCI
77285 99215 NCCI
77285 99217 NCCI
77285 99218 NCCI
77285 99219 NCCI
77285 99220 NCCI
77285 99221 NCCI
77285 99222 NCCI
77285 99223 NCCI
77285 99224 NCCI
77285 99225 NCCI
77285 99226 NCCI
77285 99231 NCCI
77285 99232 NCCI
77285 99233 NCCI
77285 99234 NCCI
77285 99235 NCCI
77285 99236 NCCI
77285 99238 NCCI
77285 99239 NCCI
77285 99281 NCCI
77285 99282 NCCI
77285 99283 NCCI
77285 99284 NCCI
77285 99285 NCCI
77285 99291 NCCI
77285 99292 NCCI
77285 99304 NCCI
77285 99305 NCCI
77285 99306 NCCI
77285 99307 NCCI
77285 99308 NCCI
77285 99309 NCCI
77285 99310 NCCI
77285 99315 NCCI
77285 99316 NCCI
77285 99318 NCCI
Comprehensive ComponentCode Code Source
77285 99324 NCCI
77285 99325 NCCI
77285 99326 NCCI
77285 99327 NCCI
77285 99328 NCCI
77285 99334 NCCI
77285 99335 NCCI
77285 99336 NCCI
77285 99337 NCCI
77285 99341 NCCI
77285 99342 NCCI
77285 99343 NCCI
77285 99344 NCCI
77285 99345 NCCI
77285 99347 NCCI
77285 99348 NCCI
77285 99349 NCCI
77285 99350 NCCI
77285 99354 NCCI
77285 99355 NCCI
77285 99356 NCCI
77285 99357 NCCI
77285 99360 NCCI
77285 99455 NCCI
77285 99456 NCCI
77285 99460 NCCI
77285 99461 NCCI
77285 99462 NCCI
77285 99463 NCCI
77285 99464 NCCI
77285 99465 NCCI
77285 99466 NCCI
77285 99467 NCCI
77285 99468 NCCI
77285 99469 NCCI
77285 99471 NCCI
77285 99472 NCCI
77285 99475 NCCI
77285 99476 NCCI
77285 99477 NCCI
77285 99478 NCCI
77285 99479 NCCI
77285 99480 NCCI
77285 99485 NCCI
77285 G0459 NCCI
77285 M0064 NCCI
77290 11920 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 66 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77290 11921 NCCI
77290 16000 NCCI
77290 16020 NCCI
77290 16025 NCCI
77290 16030 NCCI
77290 36000 NCCI
77290 36410 NCCI
77290 36425 NCCI
77290 51701 NCCI
77290 51702 NCCI
77290 51703 NCCI
77290 76000 NCCI
77290 76001 NCCI
77290 76376 NCCI
77290 76377 NCCI
77290 77280 NCCI
77290 77285 NCCI
77290 77290 CPT
77290 77336 NCCI
77290 90832 NCCI
77290 90833 NCCI
77290 90834 NCCI
77290 90836 NCCI
77290 90837 NCCI
77290 90838 NCCI
77290 90839 NCCI
77290 90846 NCCI
77290 90847 NCCI
77290 96360 NCCI
77290 96361 NCCI
77290 96365 NCCI
77290 96366 NCCI
77290 96367 NCCI
77290 96368 NCCI
77290 97802 NCCI
77290 97803 NCCI
77290 97804 NCCI
77290 99143 NCCI
77290 99144 NCCI
77290 99145 NCCI
77290 99201 NCCI
77290 99202 NCCI
77290 99203 NCCI
77290 99204 NCCI
77290 99205 NCCI
77290 99211 NCCI
77290 99212 NCCI
Comprehensive ComponentCode Code Source
77290 99213 NCCI
77290 99214 NCCI
77290 99215 NCCI
77290 99217 NCCI
77290 99218 NCCI
77290 99219 NCCI
77290 99220 NCCI
77290 99221 NCCI
77290 99222 NCCI
77290 99223 NCCI
77290 99224 NCCI
77290 99225 NCCI
77290 99226 NCCI
77290 99231 NCCI
77290 99232 NCCI
77290 99233 NCCI
77290 99234 NCCI
77290 99235 NCCI
77290 99236 NCCI
77290 99238 NCCI
77290 99239 NCCI
77290 99281 NCCI
77290 99282 NCCI
77290 99283 NCCI
77290 99284 NCCI
77290 99285 NCCI
77290 99291 NCCI
77290 99292 NCCI
77290 99304 NCCI
77290 99305 NCCI
77290 99306 NCCI
77290 99307 NCCI
77290 99308 NCCI
77290 99309 NCCI
77290 99310 NCCI
77290 99315 NCCI
77290 99316 NCCI
77290 99318 NCCI
77290 99324 NCCI
77290 99325 NCCI
77290 99326 NCCI
77290 99327 NCCI
77290 99328 NCCI
77290 99334 NCCI
77290 99335 NCCI
77290 99336 NCCI
77290 99337 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 67 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77290 99341 NCCI
77290 99342 NCCI
77290 99343 NCCI
77290 99344 NCCI
77290 99345 NCCI
77290 99347 NCCI
77290 99348 NCCI
77290 99349 NCCI
77290 99350 NCCI
77290 99354 NCCI
77290 99355 NCCI
77290 99356 NCCI
77290 99357 NCCI
77290 99360 NCCI
77290 99455 NCCI
77290 99456 NCCI
77290 99460 NCCI
77290 99461 NCCI
77290 99462 NCCI
77290 99463 NCCI
77290 99464 NCCI
77290 99465 NCCI
77290 99466 NCCI
77290 99467 NCCI
77290 99468 NCCI
77290 99469 NCCI
77290 99471 NCCI
77290 99472 NCCI
77290 99475 NCCI
77290 99476 NCCI
77290 99477 NCCI
77290 99478 NCCI
77290 99479 NCCI
77290 99480 NCCI
77290 99485 NCCI
77290 G0459 NCCI
77290 M0064 NCCI
77295 11920 NCCI
77295 11921 NCCI
77295 16000 NCCI
77295 16020 NCCI
77295 16025 NCCI
77295 16030 NCCI
77295 36000 NCCI
77295 36410 NCCI
77295 36425 NCCI
77295 51701 NCCI
Comprehensive ComponentCode Code Source
77295 51702 NCCI
77295 51703 NCCI
77295 76376 NCCI
77295 76377 NCCI
77295 77014 NCCI
77295 77280 NCCI
77295 77285 NCCI
77295 77290 NCCI
77295 77295 CPT
77295 77305 NCCI
77295 77310 NCCI
77295 77315 NCCI
77295 77336 NCCI
77295 90832 NCCI
77295 90833 NCCI
77295 90834 NCCI
77295 90836 NCCI
77295 90837 NCCI
77295 90838 NCCI
77295 90839 NCCI
77295 90846 NCCI
77295 90847 NCCI
77295 96360 NCCI
77295 96361 NCCI
77295 96365 NCCI
77295 96366 NCCI
77295 96367 NCCI
77295 96368 NCCI
77295 97802 NCCI
77295 97803 NCCI
77295 97804 NCCI
77295 99143 NCCI
77295 99144 NCCI
77295 99145 NCCI
77295 99201 NCCI
77295 99202 NCCI
77295 99203 NCCI
77295 99204 NCCI
77295 99205 NCCI
77295 99211 NCCI
77295 99212 NCCI
77295 99213 NCCI
77295 99214 NCCI
77295 99215 NCCI
77295 99217 NCCI
77295 99218 NCCI
77295 99219 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 68 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77295 99220 NCCI
77295 99221 NCCI
77295 99222 NCCI
77295 99223 NCCI
77295 99224 NCCI
77295 99225 NCCI
77295 99226 NCCI
77295 99231 NCCI
77295 99232 NCCI
77295 99233 NCCI
77295 99234 NCCI
77295 99235 NCCI
77295 99236 NCCI
77295 99238 NCCI
77295 99239 NCCI
77295 99281 NCCI
77295 99282 NCCI
77295 99283 NCCI
77295 99284 NCCI
77295 99285 NCCI
77295 99291 NCCI
77295 99292 NCCI
77295 99304 NCCI
77295 99305 NCCI
77295 99306 NCCI
77295 99307 NCCI
77295 99308 NCCI
77295 99309 NCCI
77295 99310 NCCI
77295 99315 NCCI
77295 99316 NCCI
77295 99318 NCCI
77295 99324 NCCI
77295 99325 NCCI
77295 99326 NCCI
77295 99327 NCCI
77295 99328 NCCI
77295 99334 NCCI
77295 99335 NCCI
77295 99336 NCCI
77295 99337 NCCI
77295 99341 NCCI
77295 99342 NCCI
77295 99343 NCCI
77295 99344 NCCI
77295 99345 NCCI
77295 99347 NCCI
Comprehensive ComponentCode Code Source
77295 99348 NCCI
77295 99349 NCCI
77295 99350 NCCI
77295 99354 NCCI
77295 99355 NCCI
77295 99356 NCCI
77295 99357 NCCI
77295 99360 NCCI
77295 99455 NCCI
77295 99456 NCCI
77295 99460 NCCI
77295 99461 NCCI
77295 99462 NCCI
77295 99463 NCCI
77295 99464 NCCI
77295 99465 NCCI
77295 99466 NCCI
77295 99467 NCCI
77295 99468 NCCI
77295 99469 NCCI
77295 99471 NCCI
77295 99472 NCCI
77295 99475 NCCI
77295 99476 NCCI
77295 99477 NCCI
77295 99478 NCCI
77295 99479 NCCI
77295 99480 NCCI
77295 99485 NCCI
77295 G0459 NCCI
77295 M0064 NCCI
77300 11920 NCCI
77300 11921 NCCI
77300 16000 NCCI
77300 16020 NCCI
77300 16025 NCCI
77300 16030 NCCI
77300 36000 NCCI
77300 36410 NCCI
77300 36425 NCCI
77300 51701 NCCI
77300 51702 NCCI
77300 51703 NCCI
77300 77331 NCCI
77300 90832 NCCI
77300 90833 NCCI
77300 90834 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 69 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77300 90836 NCCI
77300 90837 NCCI
77300 90838 NCCI
77300 90839 NCCI
77300 90846 NCCI
77300 90847 NCCI
77300 96360 NCCI
77300 96361 NCCI
77300 96365 NCCI
77300 96366 NCCI
77300 96367 NCCI
77300 96368 NCCI
77300 97802 NCCI
77300 97803 NCCI
77300 97804 NCCI
77300 99143 NCCI
77300 99144 NCCI
77300 99145 NCCI
77300 99201 NCCI
77300 99202 NCCI
77300 99203 NCCI
77300 99204 NCCI
77300 99205 NCCI
77300 99211 NCCI
77300 99212 NCCI
77300 99213 NCCI
77300 99214 NCCI
77300 99215 NCCI
77300 99217 NCCI
77300 99218 NCCI
77300 99219 NCCI
77300 99220 NCCI
77300 99221 NCCI
77300 99222 NCCI
77300 99223 NCCI
77300 99224 NCCI
77300 99225 NCCI
77300 99226 NCCI
77300 99231 NCCI
77300 99232 NCCI
77300 99233 NCCI
77300 99234 NCCI
77300 99235 NCCI
77300 99236 NCCI
77300 99238 NCCI
77300 99239 NCCI
77300 99281 NCCI
Comprehensive ComponentCode Code Source
77300 99282 NCCI
77300 99283 NCCI
77300 99284 NCCI
77300 99285 NCCI
77300 99291 NCCI
77300 99292 NCCI
77300 99304 NCCI
77300 99305 NCCI
77300 99306 NCCI
77300 99307 NCCI
77300 99308 NCCI
77300 99309 NCCI
77300 99310 NCCI
77300 99315 NCCI
77300 99316 NCCI
77300 99318 NCCI
77300 99324 NCCI
77300 99325 NCCI
77300 99326 NCCI
77300 99327 NCCI
77300 99328 NCCI
77300 99334 NCCI
77300 99335 NCCI
77300 99336 NCCI
77300 99337 NCCI
77300 99341 NCCI
77300 99342 NCCI
77300 99343 NCCI
77300 99344 NCCI
77300 99345 NCCI
77300 99347 NCCI
77300 99348 NCCI
77300 99349 NCCI
77300 99350 NCCI
77300 99354 NCCI
77300 99355 NCCI
77300 99356 NCCI
77300 99357 NCCI
77300 99360 NCCI
77300 99455 NCCI
77300 99456 NCCI
77300 99460 NCCI
77300 99461 NCCI
77300 99462 NCCI
77300 99463 NCCI
77300 99464 NCCI
77300 99465 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 70 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77300 99466 NCCI
77300 99467 NCCI
77300 99468 NCCI
77300 99469 NCCI
77300 99471 NCCI
77300 99472 NCCI
77300 99475 NCCI
77300 99476 NCCI
77300 99477 NCCI
77300 99478 NCCI
77300 99479 NCCI
77300 99480 NCCI
77300 99485 NCCI
77300 G0459 NCCI
77300 M0064 NCCI
77301 11920 BCBST
77301 11921 BCBST
77301 16000 BCBST
77301 16020 BCBST
77301 16025 BCBST
77301 16030 BCBST
77301 36000 NCCI
77301 36410 NCCI
77301 36425 NCCI
77301 51701 NCCI
77301 51702 NCCI
77301 51703 NCCI
77301 70450 NCCI
77301 70460 NCCI
77301 70470 NCCI
77301 70480 NCCI
77301 70481 NCCI
77301 70482 NCCI
77301 70486 NCCI
77301 70487 NCCI
77301 70488 NCCI
77301 70490 NCCI
77301 70491 NCCI
77301 70492 NCCI
77301 70496 NCCI
77301 70498 NCCI
77301 71250 NCCI
77301 71260 NCCI
77301 71270 NCCI
77301 71275 NCCI
77301 72125 NCCI
77301 72126 NCCI
Comprehensive ComponentCode Code Source
77301 72127 NCCI
77301 72128 NCCI
77301 72129 NCCI
77301 72130 NCCI
77301 72131 NCCI
77301 72132 NCCI
77301 72133 NCCI
77301 72191 NCCI
77301 72192 NCCI
77301 72193 NCCI
77301 72194 NCCI
77301 73200 NCCI
77301 73201 NCCI
77301 73202 NCCI
77301 73206 NCCI
77301 73700 NCCI
77301 73701 NCCI
77301 73702 NCCI
77301 73706 NCCI
77301 74150 NCCI
77301 74160 NCCI
77301 74170 NCCI
77301 74174 NCCI
77301 74175 NCCI
77301 74176 NCCI
77301 74177 NCCI
77301 74178 NCCI
77301 75635 NCCI
77301 76376 NCCI
77301 76377 NCCI
77301 76380 NCCI
77301 76950 NCCI
77301 77014 NCCI
77301 77261 NCCI
77301 77262 NCCI
77301 77263 NCCI
77301 77280 NCCI
77301 77285 NCCI
77301 77290 NCCI
77301 77295 NCCI
77301 77301 CPT
77301 77305 NCCI
77301 77310 NCCI
77301 77315 NCCI
77301 77321 NCCI
77301 77326 NCCI
77301 77327 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 71 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77301 77328 NCCI
77301 77331 NCCI
77301 77332 NCCI
77301 77333 NCCI
77301 77334 NCCI
77301 77336 NCCI
77301 77370 NCCI
77301 77401 NCCI
77301 77402 NCCI
77301 77403 NCCI
77301 77404 NCCI
77301 77406 NCCI
77301 77407 NCCI
77301 77408 NCCI
77301 77409 NCCI
77301 77411 NCCI
77301 77412 NCCI
77301 77413 NCCI
77301 77414 NCCI
77301 77416 NCCI
77301 77417 NCCI
77301 77421 NCCI
77301 77422 NCCI
77301 77423 NCCI
77301 77431 NCCI
77301 77432 NCCI
77301 77435 NCCI
77301 77469 NCCI
77301 77470 NCCI
77301 77520 NCCI
77301 77522 NCCI
77301 77523 NCCI
77301 77525 NCCI
77301 90832 NCCI
77301 90833 NCCI
77301 90834 NCCI
77301 90836 NCCI
77301 90837 NCCI
77301 90838 NCCI
77301 90839 NCCI
77301 90846 NCCI
77301 90847 BCBST
77301 96360 NCCI
77301 96361 NCCI
77301 96365 NCCI
77301 96366 NCCI
77301 96367 NCCI
Comprehensive ComponentCode Code Source
77301 96368 NCCI
77301 97802 NCCI
77301 97803 NCCI
77301 97804 NCCI
77301 99143 NCCI
77301 99144 NCCI
77301 99145 NCCI
77301 99201 BCBST
77301 99202 BCBST
77301 99203 BCBST
77301 99204 BCBST
77301 99205 BCBST
77301 99211 BCBST
77301 99212 BCBST
77301 99213 BCBST
77301 99214 BCBST
77301 99215 BCBST
77301 99217 BCBST
77301 99218 BCBST
77301 99219 BCBST
77301 99220 BCBST
77301 99221 BCBST
77301 99222 BCBST
77301 99223 BCBST
77301 99224 NCCI
77301 99225 NCCI
77301 99226 NCCI
77301 99231 BCBST
77301 99232 BCBST
77301 99233 BCBST
77301 99234 BCBST
77301 99235 BCBST
77301 99236 BCBST
77301 99238 BCBST
77301 99239 NCCI
77301 99281 NCCI
77301 99282 NCCI
77301 99283 NCCI
77301 99284 NCCI
77301 99285 NCCI
77301 99291 NCCI
77301 99292 NCCI
77301 99304 NCCI
77301 99305 NCCI
77301 99306 NCCI
77301 99307 NCCI
77301 99308 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 72 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77301 99309 NCCI
77301 99310 NCCI
77301 99315 NCCI
77301 99316 NCCI
77301 99318 NCCI
77301 99324 NCCI
77301 99325 NCCI
77301 99326 NCCI
77301 99327 NCCI
77301 99328 NCCI
77301 99334 NCCI
77301 99335 NCCI
77301 99336 NCCI
77301 99337 NCCI
77301 99341 NCCI
77301 99342 NCCI
77301 99343 NCCI
77301 99344 NCCI
77301 99345 NCCI
77301 99347 NCCI
77301 99348 NCCI
77301 99349 NCCI
77301 99350 NCCI
77301 99354 BCBST
77301 99355 NCCI
77301 99356 BCBST
77301 99357 NCCI
77301 99360 NCCI
77301 99455 NCCI
77301 99456 NCCI
77301 99460 NCCI
77301 99461 NCCI
77301 99462 NCCI
77301 99463 NCCI
77301 99464 NCCI
77301 99465 NCCI
77301 99466 NCCI
77301 99467 NCCI
77301 99468 NCCI
77301 99469 NCCI
77301 99471 NCCI
77301 99472 NCCI
77301 99475 NCCI
77301 99476 NCCI
77301 99477 NCCI
77301 99478 NCCI
77301 99479 NCCI
Comprehensive ComponentCode Code Source
77301 99480 NCCI
77301 99485 NCCI
77301 G0459 NCCI
77301 M0064 NCCI
77305 11920 NCCI
77305 11921 NCCI
77305 16000 NCCI
77305 16020 NCCI
77305 16025 NCCI
77305 16030 NCCI
77305 36000 NCCI
77305 36410 NCCI
77305 36425 NCCI
77305 51701 NCCI
77305 51702 NCCI
77305 51703 NCCI
77305 76376 NCCI
77305 76377 NCCI
77305 77014 NCCI
77305 77305 CPT
77305 77336 NCCI
77305 90832 NCCI
77305 90833 NCCI
77305 90834 NCCI
77305 90836 NCCI
77305 90837 NCCI
77305 90838 NCCI
77305 90839 NCCI
77305 90846 NCCI
77305 90847 NCCI
77305 96360 NCCI
77305 96361 NCCI
77305 96365 NCCI
77305 96366 NCCI
77305 96367 NCCI
77305 96368 NCCI
77305 97802 NCCI
77305 97803 NCCI
77305 97804 NCCI
77305 99143 NCCI
77305 99144 NCCI
77305 99145 NCCI
77305 99201 NCCI
77305 99202 NCCI
77305 99203 NCCI
77305 99204 NCCI
77305 99205 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 73 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77305 99211 NCCI
77305 99212 NCCI
77305 99213 NCCI
77305 99214 NCCI
77305 99215 NCCI
77305 99217 NCCI
77305 99218 NCCI
77305 99219 NCCI
77305 99220 NCCI
77305 99221 NCCI
77305 99222 NCCI
77305 99223 NCCI
77305 99224 NCCI
77305 99225 NCCI
77305 99226 NCCI
77305 99231 NCCI
77305 99232 NCCI
77305 99233 NCCI
77305 99234 NCCI
77305 99235 NCCI
77305 99236 NCCI
77305 99238 NCCI
77305 99239 NCCI
77305 99281 NCCI
77305 99282 NCCI
77305 99283 NCCI
77305 99284 NCCI
77305 99285 NCCI
77305 99291 NCCI
77305 99292 NCCI
77305 99304 NCCI
77305 99305 NCCI
77305 99306 NCCI
77305 99307 NCCI
77305 99308 NCCI
77305 99309 NCCI
77305 99310 NCCI
77305 99315 NCCI
77305 99316 NCCI
77305 99318 NCCI
77305 99324 NCCI
77305 99325 NCCI
77305 99326 NCCI
77305 99327 NCCI
77305 99328 NCCI
77305 99334 NCCI
77305 99335 NCCI
Comprehensive ComponentCode Code Source
77305 99336 NCCI
77305 99337 NCCI
77305 99341 NCCI
77305 99342 NCCI
77305 99343 NCCI
77305 99344 NCCI
77305 99345 NCCI
77305 99347 NCCI
77305 99348 NCCI
77305 99349 NCCI
77305 99350 NCCI
77305 99354 NCCI
77305 99355 NCCI
77305 99356 NCCI
77305 99357 NCCI
77305 99360 NCCI
77305 99455 NCCI
77305 99456 NCCI
77305 99460 NCCI
77305 99461 NCCI
77305 99462 NCCI
77305 99463 NCCI
77305 99464 NCCI
77305 99465 NCCI
77305 99466 NCCI
77305 99467 NCCI
77305 99468 NCCI
77305 99469 NCCI
77305 99471 NCCI
77305 99472 NCCI
77305 99475 NCCI
77305 99476 NCCI
77305 99477 NCCI
77305 99478 NCCI
77305 99479 NCCI
77305 99480 NCCI
77305 99485 NCCI
77305 G0459 NCCI
77305 M0064 NCCI
77310 11920 NCCI
77310 11921 NCCI
77310 16000 NCCI
77310 16020 NCCI
77310 16025 NCCI
77310 16030 NCCI
77310 36000 NCCI
77310 36410 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 74 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77310 36425 NCCI
77310 51701 NCCI
77310 51702 NCCI
77310 51703 NCCI
77310 76376 NCCI
77310 76377 NCCI
77310 77014 NCCI
77310 77305 NCCI
77310 77310 CPT
77310 77336 NCCI
77310 90832 NCCI
77310 90833 NCCI
77310 90834 NCCI
77310 90836 NCCI
77310 90837 NCCI
77310 90838 NCCI
77310 90839 NCCI
77310 90846 NCCI
77310 90847 NCCI
77310 96360 NCCI
77310 96361 NCCI
77310 96365 NCCI
77310 96366 NCCI
77310 96367 NCCI
77310 96368 NCCI
77310 97802 NCCI
77310 97803 NCCI
77310 97804 NCCI
77310 99143 NCCI
77310 99144 NCCI
77310 99145 NCCI
77310 99201 NCCI
77310 99202 NCCI
77310 99203 NCCI
77310 99204 NCCI
77310 99205 NCCI
77310 99211 NCCI
77310 99212 NCCI
77310 99213 NCCI
77310 99214 NCCI
77310 99215 NCCI
77310 99217 NCCI
77310 99218 NCCI
77310 99219 NCCI
77310 99220 NCCI
77310 99221 NCCI
77310 99222 NCCI
Comprehensive ComponentCode Code Source
77310 99223 NCCI
77310 99224 NCCI
77310 99225 NCCI
77310 99226 NCCI
77310 99231 NCCI
77310 99232 NCCI
77310 99233 NCCI
77310 99234 NCCI
77310 99235 NCCI
77310 99236 NCCI
77310 99238 NCCI
77310 99239 NCCI
77310 99281 NCCI
77310 99282 NCCI
77310 99283 NCCI
77310 99284 NCCI
77310 99285 NCCI
77310 99291 NCCI
77310 99292 NCCI
77310 99304 NCCI
77310 99305 NCCI
77310 99306 NCCI
77310 99307 NCCI
77310 99308 NCCI
77310 99309 NCCI
77310 99310 NCCI
77310 99315 NCCI
77310 99316 NCCI
77310 99318 NCCI
77310 99324 NCCI
77310 99325 NCCI
77310 99326 NCCI
77310 99327 NCCI
77310 99328 NCCI
77310 99334 NCCI
77310 99335 NCCI
77310 99336 NCCI
77310 99337 NCCI
77310 99341 NCCI
77310 99342 NCCI
77310 99343 NCCI
77310 99344 NCCI
77310 99345 NCCI
77310 99347 NCCI
77310 99348 NCCI
77310 99349 NCCI
77310 99350 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 75 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77310 99354 NCCI
77310 99355 NCCI
77310 99356 NCCI
77310 99357 NCCI
77310 99360 NCCI
77310 99455 NCCI
77310 99456 NCCI
77310 99460 NCCI
77310 99461 NCCI
77310 99462 NCCI
77310 99463 NCCI
77310 99464 NCCI
77310 99465 NCCI
77310 99466 NCCI
77310 99467 NCCI
77310 99468 NCCI
77310 99469 NCCI
77310 99471 NCCI
77310 99472 NCCI
77310 99475 NCCI
77310 99476 NCCI
77310 99477 NCCI
77310 99478 NCCI
77310 99479 NCCI
77310 99480 NCCI
77310 99485 NCCI
77310 G0459 NCCI
77310 M0064 NCCI
77315 11920 NCCI
77315 11921 NCCI
77315 16000 NCCI
77315 16020 NCCI
77315 16025 NCCI
77315 16030 NCCI
77315 36000 NCCI
77315 36410 NCCI
77315 36425 NCCI
77315 51701 NCCI
77315 51702 NCCI
77315 51703 NCCI
77315 76376 NCCI
77315 76377 NCCI
77315 77014 NCCI
77315 77305 NCCI
77315 77310 NCCI
77315 77315 CPT
77315 77336 NCCI
Comprehensive ComponentCode Code Source
77315 90832 NCCI
77315 90833 NCCI
77315 90834 NCCI
77315 90836 NCCI
77315 90837 NCCI
77315 90838 NCCI
77315 90839 NCCI
77315 90846 NCCI
77315 90847 NCCI
77315 96360 NCCI
77315 96361 NCCI
77315 96365 NCCI
77315 96366 NCCI
77315 96367 NCCI
77315 96368 NCCI
77315 97802 NCCI
77315 97803 NCCI
77315 97804 NCCI
77315 99143 NCCI
77315 99144 NCCI
77315 99145 NCCI
77315 99201 NCCI
77315 99202 NCCI
77315 99203 NCCI
77315 99204 NCCI
77315 99205 NCCI
77315 99211 NCCI
77315 99212 NCCI
77315 99213 NCCI
77315 99214 NCCI
77315 99215 NCCI
77315 99217 NCCI
77315 99218 NCCI
77315 99219 NCCI
77315 99220 NCCI
77315 99221 NCCI
77315 99222 NCCI
77315 99223 NCCI
77315 99224 NCCI
77315 99225 NCCI
77315 99226 NCCI
77315 99231 NCCI
77315 99232 NCCI
77315 99233 NCCI
77315 99234 NCCI
77315 99235 NCCI
77315 99236 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 76 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77315 99238 NCCI
77315 99239 NCCI
77315 99281 NCCI
77315 99282 NCCI
77315 99283 NCCI
77315 99284 NCCI
77315 99285 NCCI
77315 99291 NCCI
77315 99292 NCCI
77315 99304 NCCI
77315 99305 NCCI
77315 99306 NCCI
77315 99307 NCCI
77315 99308 NCCI
77315 99309 NCCI
77315 99310 NCCI
77315 99315 NCCI
77315 99316 NCCI
77315 99318 NCCI
77315 99324 NCCI
77315 99325 NCCI
77315 99326 NCCI
77315 99327 NCCI
77315 99328 NCCI
77315 99334 NCCI
77315 99335 NCCI
77315 99336 NCCI
77315 99337 NCCI
77315 99341 NCCI
77315 99342 NCCI
77315 99343 NCCI
77315 99344 NCCI
77315 99345 NCCI
77315 99347 NCCI
77315 99348 NCCI
77315 99349 NCCI
77315 99350 NCCI
77315 99354 NCCI
77315 99355 NCCI
77315 99356 NCCI
77315 99357 NCCI
77315 99360 NCCI
77315 99455 NCCI
77315 99456 NCCI
77315 99460 NCCI
77315 99461 NCCI
77315 99462 NCCI
Comprehensive ComponentCode Code Source
77315 99463 NCCI
77315 99464 NCCI
77315 99465 NCCI
77315 99466 NCCI
77315 99467 NCCI
77315 99468 NCCI
77315 99469 NCCI
77315 99471 NCCI
77315 99472 NCCI
77315 99475 NCCI
77315 99476 NCCI
77315 99477 NCCI
77315 99478 NCCI
77315 99479 NCCI
77315 99480 NCCI
77315 99485 NCCI
77315 G0459 NCCI
77315 M0064 NCCI
77321 11920 NCCI
77321 11921 NCCI
77321 16000 NCCI
77321 16020 NCCI
77321 16025 NCCI
77321 16030 NCCI
77321 36000 NCCI
77321 36410 NCCI
77321 36425 NCCI
77321 51701 NCCI
77321 51702 NCCI
77321 51703 NCCI
77321 77305 NCCI
77321 77310 NCCI
77321 77315 NCCI
77321 77321 BCBST
77321 77336 NCCI
77321 90832 NCCI
77321 90833 NCCI
77321 90834 NCCI
77321 90836 NCCI
77321 90837 NCCI
77321 90838 NCCI
77321 90839 NCCI
77321 90846 NCCI
77321 90847 NCCI
77321 96360 NCCI
77321 96361 NCCI
77321 96365 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 77 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77321 96366 NCCI
77321 96367 NCCI
77321 96368 NCCI
77321 97802 NCCI
77321 97803 NCCI
77321 97804 NCCI
77321 99143 NCCI
77321 99144 NCCI
77321 99145 NCCI
77321 99201 NCCI
77321 99202 NCCI
77321 99203 NCCI
77321 99204 NCCI
77321 99205 NCCI
77321 99211 NCCI
77321 99212 NCCI
77321 99213 NCCI
77321 99214 NCCI
77321 99215 NCCI
77321 99217 NCCI
77321 99218 NCCI
77321 99219 NCCI
77321 99220 NCCI
77321 99221 NCCI
77321 99222 NCCI
77321 99223 NCCI
77321 99224 NCCI
77321 99225 NCCI
77321 99226 NCCI
77321 99231 NCCI
77321 99232 NCCI
77321 99233 NCCI
77321 99234 NCCI
77321 99235 NCCI
77321 99236 NCCI
77321 99238 NCCI
77321 99239 NCCI
77321 99281 NCCI
77321 99282 NCCI
77321 99283 NCCI
77321 99284 NCCI
77321 99285 NCCI
77321 99291 NCCI
77321 99292 NCCI
77321 99304 NCCI
77321 99305 NCCI
77321 99306 NCCI
Comprehensive ComponentCode Code Source
77321 99307 NCCI
77321 99308 NCCI
77321 99309 NCCI
77321 99310 NCCI
77321 99315 NCCI
77321 99316 NCCI
77321 99318 NCCI
77321 99324 NCCI
77321 99325 NCCI
77321 99326 NCCI
77321 99327 NCCI
77321 99328 NCCI
77321 99334 NCCI
77321 99335 NCCI
77321 99336 NCCI
77321 99337 NCCI
77321 99341 NCCI
77321 99342 NCCI
77321 99343 NCCI
77321 99344 NCCI
77321 99345 NCCI
77321 99347 NCCI
77321 99348 NCCI
77321 99349 NCCI
77321 99350 NCCI
77321 99354 NCCI
77321 99355 NCCI
77321 99356 NCCI
77321 99357 NCCI
77321 99360 NCCI
77321 99455 NCCI
77321 99456 NCCI
77321 99460 NCCI
77321 99461 NCCI
77321 99462 NCCI
77321 99463 NCCI
77321 99464 NCCI
77321 99465 NCCI
77321 99466 NCCI
77321 99467 NCCI
77321 99468 NCCI
77321 99469 NCCI
77321 99471 NCCI
77321 99472 NCCI
77321 99475 NCCI
77321 99476 NCCI
77321 99477 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 78 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77321 99478 NCCI
77321 99479 NCCI
77321 99480 NCCI
77321 99485 NCCI
77321 G0459 NCCI
77321 M0064 NCCI
77326 11920 NCCI
77326 11921 NCCI
77326 16000 NCCI
77326 16020 NCCI
77326 16025 NCCI
77326 16030 NCCI
77326 36000 NCCI
77326 36410 NCCI
77326 36425 NCCI
77326 51701 NCCI
77326 51702 NCCI
77326 51703 NCCI
77326 76376 NCCI
77326 76377 NCCI
77326 77326 CPT
77326 77336 NCCI
77326 90832 NCCI
77326 90833 NCCI
77326 90834 NCCI
77326 90836 NCCI
77326 90837 NCCI
77326 90838 NCCI
77326 90839 NCCI
77326 90846 NCCI
77326 90847 NCCI
77326 96360 NCCI
77326 96361 NCCI
77326 96365 NCCI
77326 96366 NCCI
77326 96367 NCCI
77326 96368 NCCI
77326 97802 NCCI
77326 97803 NCCI
77326 97804 NCCI
77326 99143 NCCI
77326 99144 NCCI
77326 99145 NCCI
77326 99201 NCCI
77326 99202 NCCI
77326 99203 NCCI
77326 99204 NCCI
Comprehensive ComponentCode Code Source
77326 99205 NCCI
77326 99211 NCCI
77326 99212 NCCI
77326 99213 NCCI
77326 99214 NCCI
77326 99215 NCCI
77326 99217 NCCI
77326 99218 NCCI
77326 99219 NCCI
77326 99220 NCCI
77326 99221 NCCI
77326 99222 NCCI
77326 99223 NCCI
77326 99224 NCCI
77326 99225 NCCI
77326 99226 NCCI
77326 99231 NCCI
77326 99232 NCCI
77326 99233 NCCI
77326 99234 NCCI
77326 99235 NCCI
77326 99236 NCCI
77326 99238 NCCI
77326 99239 NCCI
77326 99281 NCCI
77326 99282 NCCI
77326 99283 NCCI
77326 99284 NCCI
77326 99285 NCCI
77326 99291 NCCI
77326 99292 NCCI
77326 99304 NCCI
77326 99305 NCCI
77326 99306 NCCI
77326 99307 NCCI
77326 99308 NCCI
77326 99309 NCCI
77326 99310 NCCI
77326 99315 NCCI
77326 99316 NCCI
77326 99318 NCCI
77326 99324 NCCI
77326 99325 NCCI
77326 99326 NCCI
77326 99327 NCCI
77326 99328 NCCI
77326 99334 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 79 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77326 99335 NCCI
77326 99336 NCCI
77326 99337 NCCI
77326 99341 NCCI
77326 99342 NCCI
77326 99343 NCCI
77326 99344 NCCI
77326 99345 NCCI
77326 99347 NCCI
77326 99348 NCCI
77326 99349 NCCI
77326 99350 NCCI
77326 99354 NCCI
77326 99355 NCCI
77326 99356 NCCI
77326 99357 NCCI
77326 99360 NCCI
77326 99455 NCCI
77326 99456 NCCI
77326 99460 NCCI
77326 99461 NCCI
77326 99462 NCCI
77326 99463 NCCI
77326 99464 NCCI
77326 99465 NCCI
77326 99466 NCCI
77326 99467 NCCI
77326 99468 NCCI
77326 99469 NCCI
77326 99471 NCCI
77326 99472 NCCI
77326 99475 NCCI
77326 99476 NCCI
77326 99477 NCCI
77326 99478 NCCI
77326 99479 NCCI
77326 99480 NCCI
77326 99485 NCCI
77326 G0459 NCCI
77326 M0064 NCCI
77327 11920 NCCI
77327 11921 NCCI
77327 16000 NCCI
77327 16020 NCCI
77327 16025 NCCI
77327 16030 NCCI
77327 36000 NCCI
Comprehensive ComponentCode Code Source
77327 36410 NCCI
77327 36425 NCCI
77327 51701 NCCI
77327 51702 NCCI
77327 51703 NCCI
77327 76376 NCCI
77327 76377 NCCI
77327 77326 NCCI
77327 77327 CPT
77327 77336 NCCI
77327 90832 NCCI
77327 90833 NCCI
77327 90834 NCCI
77327 90836 NCCI
77327 90837 NCCI
77327 90838 NCCI
77327 90839 NCCI
77327 90846 NCCI
77327 90847 NCCI
77327 96360 NCCI
77327 96361 NCCI
77327 96365 NCCI
77327 96366 NCCI
77327 96367 NCCI
77327 96368 NCCI
77327 97802 NCCI
77327 97803 NCCI
77327 97804 NCCI
77327 99143 NCCI
77327 99144 NCCI
77327 99145 NCCI
77327 99201 NCCI
77327 99202 NCCI
77327 99203 NCCI
77327 99204 NCCI
77327 99205 NCCI
77327 99211 NCCI
77327 99212 NCCI
77327 99213 NCCI
77327 99214 NCCI
77327 99215 NCCI
77327 99217 NCCI
77327 99218 NCCI
77327 99219 NCCI
77327 99220 NCCI
77327 99221 NCCI
77327 99222 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 80 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77327 99223 NCCI
77327 99224 NCCI
77327 99225 NCCI
77327 99226 NCCI
77327 99231 NCCI
77327 99232 NCCI
77327 99233 NCCI
77327 99234 NCCI
77327 99235 NCCI
77327 99236 NCCI
77327 99238 NCCI
77327 99239 NCCI
77327 99281 NCCI
77327 99282 NCCI
77327 99283 NCCI
77327 99284 NCCI
77327 99285 NCCI
77327 99291 NCCI
77327 99292 NCCI
77327 99304 NCCI
77327 99305 NCCI
77327 99306 NCCI
77327 99307 NCCI
77327 99308 NCCI
77327 99309 NCCI
77327 99310 NCCI
77327 99315 NCCI
77327 99316 NCCI
77327 99318 NCCI
77327 99324 NCCI
77327 99325 NCCI
77327 99326 NCCI
77327 99327 NCCI
77327 99328 NCCI
77327 99334 NCCI
77327 99335 NCCI
77327 99336 NCCI
77327 99337 NCCI
77327 99341 NCCI
77327 99342 NCCI
77327 99343 NCCI
77327 99344 NCCI
77327 99345 NCCI
77327 99347 NCCI
77327 99348 NCCI
77327 99349 NCCI
77327 99350 NCCI
Comprehensive ComponentCode Code Source
77327 99354 NCCI
77327 99355 NCCI
77327 99356 NCCI
77327 99357 NCCI
77327 99360 NCCI
77327 99455 NCCI
77327 99456 NCCI
77327 99460 NCCI
77327 99461 NCCI
77327 99462 NCCI
77327 99463 NCCI
77327 99464 NCCI
77327 99465 NCCI
77327 99466 NCCI
77327 99467 NCCI
77327 99468 NCCI
77327 99469 NCCI
77327 99471 NCCI
77327 99472 NCCI
77327 99475 NCCI
77327 99476 NCCI
77327 99477 NCCI
77327 99478 NCCI
77327 99479 NCCI
77327 99480 NCCI
77327 99485 NCCI
77327 G0459 NCCI
77327 M0064 NCCI
77328 11920 NCCI
77328 11921 NCCI
77328 16000 NCCI
77328 16020 NCCI
77328 16025 NCCI
77328 16030 NCCI
77328 36000 NCCI
77328 36410 NCCI
77328 36425 NCCI
77328 51701 NCCI
77328 51702 NCCI
77328 51703 NCCI
77328 76376 NCCI
77328 76377 NCCI
77328 77326 NCCI
77328 77327 NCCI
77328 77328 CPT
77328 77336 NCCI
77328 90832 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 81 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77328 90833 NCCI
77328 90834 NCCI
77328 90836 NCCI
77328 90837 NCCI
77328 90838 NCCI
77328 90839 NCCI
77328 90846 NCCI
77328 90847 NCCI
77328 96360 NCCI
77328 96361 NCCI
77328 96365 NCCI
77328 96366 NCCI
77328 96367 NCCI
77328 96368 NCCI
77328 97802 NCCI
77328 97803 NCCI
77328 97804 NCCI
77328 99143 NCCI
77328 99144 NCCI
77328 99145 NCCI
77328 99201 NCCI
77328 99202 NCCI
77328 99203 NCCI
77328 99204 NCCI
77328 99205 NCCI
77328 99211 NCCI
77328 99212 NCCI
77328 99213 NCCI
77328 99214 NCCI
77328 99215 NCCI
77328 99217 NCCI
77328 99218 NCCI
77328 99219 NCCI
77328 99220 NCCI
77328 99221 NCCI
77328 99222 NCCI
77328 99223 NCCI
77328 99224 NCCI
77328 99225 NCCI
77328 99226 NCCI
77328 99231 NCCI
77328 99232 NCCI
77328 99233 NCCI
77328 99234 NCCI
77328 99235 NCCI
77328 99236 NCCI
77328 99238 NCCI
Comprehensive ComponentCode Code Source
77328 99239 NCCI
77328 99281 NCCI
77328 99282 NCCI
77328 99283 NCCI
77328 99284 NCCI
77328 99285 NCCI
77328 99291 NCCI
77328 99292 NCCI
77328 99304 NCCI
77328 99305 NCCI
77328 99306 NCCI
77328 99307 NCCI
77328 99308 NCCI
77328 99309 NCCI
77328 99310 NCCI
77328 99315 NCCI
77328 99316 NCCI
77328 99318 NCCI
77328 99324 NCCI
77328 99325 NCCI
77328 99326 NCCI
77328 99327 NCCI
77328 99328 NCCI
77328 99334 NCCI
77328 99335 NCCI
77328 99336 NCCI
77328 99337 NCCI
77328 99341 NCCI
77328 99342 NCCI
77328 99343 NCCI
77328 99344 NCCI
77328 99345 NCCI
77328 99347 NCCI
77328 99348 NCCI
77328 99349 NCCI
77328 99350 NCCI
77328 99354 NCCI
77328 99355 NCCI
77328 99356 NCCI
77328 99357 NCCI
77328 99360 NCCI
77328 99455 NCCI
77328 99456 NCCI
77328 99460 NCCI
77328 99461 NCCI
77328 99462 NCCI
77328 99463 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 82 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77328 99464 NCCI
77328 99465 NCCI
77328 99466 NCCI
77328 99467 NCCI
77328 99468 NCCI
77328 99469 NCCI
77328 99471 NCCI
77328 99472 NCCI
77328 99475 NCCI
77328 99476 NCCI
77328 99477 NCCI
77328 99478 NCCI
77328 99479 NCCI
77328 99480 NCCI
77328 99485 NCCI
77328 G0459 NCCI
77328 M0064 NCCI
77331 11920 NCCI
77331 11921 NCCI
77331 16000 NCCI
77331 16020 NCCI
77331 16025 NCCI
77331 16030 NCCI
77331 36000 NCCI
77331 36410 NCCI
77331 36425 NCCI
77331 51701 NCCI
77331 51702 NCCI
77331 51703 NCCI
77331 77331 BCBST
77331 90832 NCCI
77331 90833 NCCI
77331 90834 NCCI
77331 90836 NCCI
77331 90837 NCCI
77331 90838 NCCI
77331 90839 NCCI
77331 90846 NCCI
77331 90847 NCCI
77331 96360 NCCI
77331 96361 NCCI
77331 96365 NCCI
77331 96366 NCCI
77331 96367 NCCI
77331 96368 NCCI
77331 97802 NCCI
77331 97803 NCCI
Comprehensive ComponentCode Code Source
77331 97804 NCCI
77331 99143 NCCI
77331 99144 NCCI
77331 99145 NCCI
77331 99201 NCCI
77331 99202 NCCI
77331 99203 NCCI
77331 99204 NCCI
77331 99205 NCCI
77331 99211 NCCI
77331 99212 NCCI
77331 99213 NCCI
77331 99214 NCCI
77331 99215 NCCI
77331 99217 NCCI
77331 99218 NCCI
77331 99219 NCCI
77331 99220 NCCI
77331 99221 NCCI
77331 99222 NCCI
77331 99223 NCCI
77331 99224 NCCI
77331 99225 NCCI
77331 99226 NCCI
77331 99231 NCCI
77331 99232 NCCI
77331 99233 NCCI
77331 99234 NCCI
77331 99235 NCCI
77331 99236 NCCI
77331 99238 NCCI
77331 99239 NCCI
77331 99281 NCCI
77331 99282 NCCI
77331 99283 NCCI
77331 99284 NCCI
77331 99285 NCCI
77331 99291 NCCI
77331 99292 NCCI
77331 99304 NCCI
77331 99305 NCCI
77331 99306 NCCI
77331 99307 NCCI
77331 99308 NCCI
77331 99309 NCCI
77331 99310 NCCI
77331 99315 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 83 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77331 99316 NCCI
77331 99318 NCCI
77331 99324 NCCI
77331 99325 NCCI
77331 99326 NCCI
77331 99327 NCCI
77331 99328 NCCI
77331 99334 NCCI
77331 99335 NCCI
77331 99336 NCCI
77331 99337 NCCI
77331 99341 NCCI
77331 99342 NCCI
77331 99343 NCCI
77331 99344 NCCI
77331 99345 NCCI
77331 99347 NCCI
77331 99348 NCCI
77331 99349 NCCI
77331 99350 NCCI
77331 99354 NCCI
77331 99355 NCCI
77331 99356 NCCI
77331 99357 NCCI
77331 99360 NCCI
77331 99455 NCCI
77331 99456 NCCI
77331 99460 NCCI
77331 99461 NCCI
77331 99462 NCCI
77331 99463 NCCI
77331 99464 NCCI
77331 99465 NCCI
77331 99466 NCCI
77331 99467 NCCI
77331 99468 NCCI
77331 99469 NCCI
77331 99471 NCCI
77331 99472 NCCI
77331 99475 NCCI
77331 99476 NCCI
77331 99477 NCCI
77331 99478 NCCI
77331 99479 NCCI
77331 99480 NCCI
77331 99485 NCCI
77331 G0459 NCCI
Comprehensive ComponentCode Code Source
77331 M0064 NCCI
77332 11920 NCCI
77332 11921 NCCI
77332 16000 NCCI
77332 16020 NCCI
77332 16025 NCCI
77332 16030 NCCI
77332 36000 NCCI
77332 36410 NCCI
77332 36425 NCCI
77332 51701 NCCI
77332 51702 NCCI
77332 51703 NCCI
77332 77332 CPT
77332 77336 NCCI
77332 90832 NCCI
77332 90833 NCCI
77332 90834 NCCI
77332 90836 NCCI
77332 90837 NCCI
77332 90838 NCCI
77332 90839 NCCI
77332 90846 NCCI
77332 90847 NCCI
77332 96360 NCCI
77332 96361 NCCI
77332 96365 NCCI
77332 96366 NCCI
77332 96367 NCCI
77332 96368 NCCI
77332 97802 NCCI
77332 97803 NCCI
77332 97804 NCCI
77332 99143 NCCI
77332 99144 NCCI
77332 99145 NCCI
77332 99201 NCCI
77332 99202 NCCI
77332 99203 NCCI
77332 99204 NCCI
77332 99205 NCCI
77332 99211 NCCI
77332 99212 NCCI
77332 99213 NCCI
77332 99214 NCCI
77332 99215 NCCI
77332 99217 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 84 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77332 99218 NCCI
77332 99219 NCCI
77332 99220 NCCI
77332 99221 NCCI
77332 99222 NCCI
77332 99223 NCCI
77332 99224 NCCI
77332 99225 NCCI
77332 99226 NCCI
77332 99231 NCCI
77332 99232 NCCI
77332 99233 NCCI
77332 99234 NCCI
77332 99235 NCCI
77332 99236 NCCI
77332 99238 NCCI
77332 99239 NCCI
77332 99281 NCCI
77332 99282 NCCI
77332 99283 NCCI
77332 99284 NCCI
77332 99285 NCCI
77332 99291 NCCI
77332 99292 NCCI
77332 99304 NCCI
77332 99305 NCCI
77332 99306 NCCI
77332 99307 NCCI
77332 99308 NCCI
77332 99309 NCCI
77332 99310 NCCI
77332 99315 NCCI
77332 99316 NCCI
77332 99318 NCCI
77332 99324 NCCI
77332 99325 NCCI
77332 99326 NCCI
77332 99327 NCCI
77332 99328 NCCI
77332 99334 NCCI
77332 99335 NCCI
77332 99336 NCCI
77332 99337 NCCI
77332 99341 NCCI
77332 99342 NCCI
77332 99343 NCCI
77332 99344 NCCI
Comprehensive ComponentCode Code Source
77332 99345 NCCI
77332 99347 NCCI
77332 99348 NCCI
77332 99349 NCCI
77332 99350 NCCI
77332 99354 NCCI
77332 99355 NCCI
77332 99356 NCCI
77332 99357 NCCI
77332 99360 NCCI
77332 99455 NCCI
77332 99456 NCCI
77332 99460 NCCI
77332 99461 NCCI
77332 99462 NCCI
77332 99463 NCCI
77332 99464 NCCI
77332 99465 NCCI
77332 99466 NCCI
77332 99467 NCCI
77332 99468 NCCI
77332 99469 NCCI
77332 99471 NCCI
77332 99472 NCCI
77332 99475 NCCI
77332 99476 NCCI
77332 99477 NCCI
77332 99478 NCCI
77332 99479 NCCI
77332 99480 NCCI
77332 99485 NCCI
77332 G0459 NCCI
77332 M0064 NCCI
77333 11920 NCCI
77333 11921 NCCI
77333 16000 NCCI
77333 16020 NCCI
77333 16025 NCCI
77333 16030 NCCI
77333 36000 NCCI
77333 36410 NCCI
77333 36425 NCCI
77333 51701 NCCI
77333 51702 NCCI
77333 51703 NCCI
77333 77332 NCCI
77333 77333 CPT
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 85 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77333 77336 NCCI
77333 90832 NCCI
77333 90833 NCCI
77333 90834 NCCI
77333 90836 NCCI
77333 90837 NCCI
77333 90838 NCCI
77333 90839 NCCI
77333 90846 NCCI
77333 90847 NCCI
77333 96360 NCCI
77333 96361 NCCI
77333 96365 NCCI
77333 96366 NCCI
77333 96367 NCCI
77333 96368 NCCI
77333 97802 NCCI
77333 97803 NCCI
77333 97804 NCCI
77333 99143 NCCI
77333 99144 NCCI
77333 99145 NCCI
77333 99201 NCCI
77333 99202 NCCI
77333 99203 NCCI
77333 99204 NCCI
77333 99205 NCCI
77333 99211 NCCI
77333 99212 NCCI
77333 99213 NCCI
77333 99214 NCCI
77333 99215 NCCI
77333 99217 NCCI
77333 99218 NCCI
77333 99219 NCCI
77333 99220 NCCI
77333 99221 NCCI
77333 99222 NCCI
77333 99223 NCCI
77333 99224 NCCI
77333 99225 NCCI
77333 99226 NCCI
77333 99231 NCCI
77333 99232 NCCI
77333 99233 NCCI
77333 99234 NCCI
77333 99235 NCCI
Comprehensive ComponentCode Code Source
77333 99236 NCCI
77333 99238 NCCI
77333 99239 NCCI
77333 99281 NCCI
77333 99282 NCCI
77333 99283 NCCI
77333 99284 NCCI
77333 99285 NCCI
77333 99291 NCCI
77333 99292 NCCI
77333 99304 NCCI
77333 99305 NCCI
77333 99306 NCCI
77333 99307 NCCI
77333 99308 NCCI
77333 99309 NCCI
77333 99310 NCCI
77333 99315 NCCI
77333 99316 NCCI
77333 99318 NCCI
77333 99324 NCCI
77333 99325 NCCI
77333 99326 NCCI
77333 99327 NCCI
77333 99328 NCCI
77333 99334 NCCI
77333 99335 NCCI
77333 99336 NCCI
77333 99337 NCCI
77333 99341 NCCI
77333 99342 NCCI
77333 99343 NCCI
77333 99344 NCCI
77333 99345 NCCI
77333 99347 NCCI
77333 99348 NCCI
77333 99349 NCCI
77333 99350 NCCI
77333 99354 NCCI
77333 99355 NCCI
77333 99356 NCCI
77333 99357 NCCI
77333 99360 NCCI
77333 99455 NCCI
77333 99456 NCCI
77333 99460 NCCI
77333 99461 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 86 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77333 99462 NCCI
77333 99463 NCCI
77333 99464 NCCI
77333 99465 NCCI
77333 99466 NCCI
77333 99467 NCCI
77333 99468 NCCI
77333 99469 NCCI
77333 99471 NCCI
77333 99472 NCCI
77333 99475 NCCI
77333 99476 NCCI
77333 99477 NCCI
77333 99478 NCCI
77333 99479 NCCI
77333 99480 NCCI
77333 99485 NCCI
77333 G0459 NCCI
77333 M0064 NCCI
77334 11920 NCCI
77334 11921 NCCI
77334 16000 NCCI
77334 16020 NCCI
77334 16025 NCCI
77334 16030 NCCI
77334 36000 NCCI
77334 36410 NCCI
77334 36425 NCCI
77334 51701 NCCI
77334 51702 NCCI
77334 51703 NCCI
77334 77332 NCCI
77334 77333 NCCI
77334 77334 CPT
77334 77336 NCCI
77334 90832 NCCI
77334 90833 NCCI
77334 90834 NCCI
77334 90836 NCCI
77334 90837 NCCI
77334 90838 NCCI
77334 90839 NCCI
77334 90846 NCCI
77334 90847 NCCI
77334 96360 NCCI
77334 96361 NCCI
77334 96365 NCCI
Comprehensive ComponentCode Code Source
77334 96366 NCCI
77334 96367 NCCI
77334 96368 NCCI
77334 97802 NCCI
77334 97803 NCCI
77334 97804 NCCI
77334 99143 NCCI
77334 99144 NCCI
77334 99145 NCCI
77334 99201 NCCI
77334 99202 NCCI
77334 99203 NCCI
77334 99204 NCCI
77334 99205 NCCI
77334 99211 NCCI
77334 99212 NCCI
77334 99213 NCCI
77334 99214 NCCI
77334 99215 NCCI
77334 99217 NCCI
77334 99218 NCCI
77334 99219 NCCI
77334 99220 NCCI
77334 99221 NCCI
77334 99222 NCCI
77334 99223 NCCI
77334 99224 NCCI
77334 99225 NCCI
77334 99226 NCCI
77334 99231 NCCI
77334 99232 NCCI
77334 99233 NCCI
77334 99234 NCCI
77334 99235 NCCI
77334 99236 NCCI
77334 99238 NCCI
77334 99239 NCCI
77334 99281 NCCI
77334 99282 NCCI
77334 99283 NCCI
77334 99284 NCCI
77334 99285 NCCI
77334 99291 NCCI
77334 99292 NCCI
77334 99304 NCCI
77334 99305 NCCI
77334 99306 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 87 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77334 99307 NCCI
77334 99308 NCCI
77334 99309 NCCI
77334 99310 NCCI
77334 99315 NCCI
77334 99316 NCCI
77334 99318 NCCI
77334 99324 NCCI
77334 99325 NCCI
77334 99326 NCCI
77334 99327 NCCI
77334 99328 NCCI
77334 99334 NCCI
77334 99335 NCCI
77334 99336 NCCI
77334 99337 NCCI
77334 99341 NCCI
77334 99342 NCCI
77334 99343 NCCI
77334 99344 NCCI
77334 99345 NCCI
77334 99347 NCCI
77334 99348 NCCI
77334 99349 NCCI
77334 99350 NCCI
77334 99354 NCCI
77334 99355 NCCI
77334 99356 NCCI
77334 99357 NCCI
77334 99360 NCCI
77334 99455 NCCI
77334 99456 NCCI
77334 99460 NCCI
77334 99461 NCCI
77334 99462 NCCI
77334 99463 NCCI
77334 99464 NCCI
77334 99465 NCCI
77334 99466 NCCI
77334 99467 NCCI
77334 99468 NCCI
77334 99469 NCCI
77334 99471 NCCI
77334 99472 NCCI
77334 99475 NCCI
77334 99476 NCCI
77334 99477 NCCI
Comprehensive ComponentCode Code Source
77334 99478 NCCI
77334 99479 NCCI
77334 99480 NCCI
77334 99485 NCCI
77334 G0459 NCCI
77334 M0064 NCCI
77336 11920 NCCI
77336 11921 NCCI
77336 16000 NCCI
77336 16020 NCCI
77336 16025 NCCI
77336 16030 NCCI
77336 36000 NCCI
77336 36410 NCCI
77336 36425 NCCI
77336 51701 NCCI
77336 51702 NCCI
77336 51703 NCCI
77336 77336 CPT
77336 77370 NCCI
77336 90832 NCCI
77336 90833 NCCI
77336 90834 NCCI
77336 90836 NCCI
77336 90837 NCCI
77336 90838 NCCI
77336 90839 NCCI
77336 90846 NCCI
77336 90847 NCCI
77336 96360 NCCI
77336 96361 NCCI
77336 96365 NCCI
77336 96366 NCCI
77336 96367 NCCI
77336 96368 NCCI
77336 97802 NCCI
77336 97803 NCCI
77336 97804 NCCI
77336 99143 NCCI
77336 99144 NCCI
77336 99145 NCCI
77336 99201 NCCI
77336 99202 NCCI
77336 99203 NCCI
77336 99204 NCCI
77336 99205 NCCI
77336 99211 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 88 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77336 99212 NCCI
77336 99213 NCCI
77336 99214 NCCI
77336 99215 NCCI
77336 99217 NCCI
77336 99218 NCCI
77336 99219 NCCI
77336 99220 NCCI
77336 99221 NCCI
77336 99222 NCCI
77336 99223 NCCI
77336 99224 NCCI
77336 99225 NCCI
77336 99226 NCCI
77336 99231 NCCI
77336 99232 NCCI
77336 99233 NCCI
77336 99234 NCCI
77336 99235 NCCI
77336 99236 NCCI
77336 99238 NCCI
77336 99239 NCCI
77336 99281 NCCI
77336 99282 NCCI
77336 99283 NCCI
77336 99284 NCCI
77336 99285 NCCI
77336 99291 NCCI
77336 99292 NCCI
77336 99304 NCCI
77336 99305 NCCI
77336 99306 NCCI
77336 99307 NCCI
77336 99308 NCCI
77336 99309 NCCI
77336 99310 NCCI
77336 99315 NCCI
77336 99316 NCCI
77336 99318 NCCI
77336 99324 NCCI
77336 99325 NCCI
77336 99326 NCCI
77336 99327 NCCI
77336 99328 NCCI
77336 99334 NCCI
77336 99335 NCCI
77336 99336 NCCI
Comprehensive ComponentCode Code Source
77336 99337 NCCI
77336 99341 NCCI
77336 99342 NCCI
77336 99343 NCCI
77336 99344 NCCI
77336 99345 NCCI
77336 99347 NCCI
77336 99348 NCCI
77336 99349 NCCI
77336 99350 NCCI
77336 99354 NCCI
77336 99355 NCCI
77336 99356 NCCI
77336 99357 NCCI
77336 99360 NCCI
77336 99455 NCCI
77336 99456 NCCI
77336 99460 NCCI
77336 99461 NCCI
77336 99462 NCCI
77336 99463 NCCI
77336 99464 NCCI
77336 99465 NCCI
77336 99466 NCCI
77336 99467 NCCI
77336 99468 NCCI
77336 99469 NCCI
77336 99471 NCCI
77336 99472 NCCI
77336 99475 NCCI
77336 99476 NCCI
77336 99477 NCCI
77336 99478 NCCI
77336 99479 NCCI
77336 99480 NCCI
77336 99485 NCCI
77336 G0459 NCCI
77336 M0064 NCCI
77338 0073T NCCI
77338 11920 NCCI
77338 11921 NCCI
77338 16000 NCCI
77338 16020 NCCI
77338 16025 NCCI
77338 16030 NCCI
77338 36000 NCCI
77338 36410 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 89 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77338 36425 NCCI
77338 51701 NCCI
77338 51702 NCCI
77338 51703 NCCI
77338 77332 NCCI
77338 77333 NCCI
77338 77334 NCCI
77338 90832 NCCI
77338 90833 NCCI
77338 90834 NCCI
77338 90836 NCCI
77338 90837 NCCI
77338 90838 NCCI
77338 90839 NCCI
77338 90846 NCCI
77338 90847 NCCI
77338 96360 NCCI
77338 96361 NCCI
77338 96365 NCCI
77338 96366 NCCI
77338 96367 NCCI
77338 96368 NCCI
77338 97802 NCCI
77338 97803 NCCI
77338 97804 NCCI
77338 99143 NCCI
77338 99144 NCCI
77338 99145 NCCI
77338 99201 NCCI
77338 99202 NCCI
77338 99203 NCCI
77338 99204 NCCI
77338 99205 NCCI
77338 99211 NCCI
77338 99212 NCCI
77338 99213 NCCI
77338 99214 NCCI
77338 99215 NCCI
77338 99217 NCCI
77338 99218 NCCI
77338 99219 NCCI
77338 99220 NCCI
77338 99221 NCCI
77338 99222 NCCI
77338 99223 NCCI
77338 99224 NCCI
77338 99225 NCCI
Comprehensive ComponentCode Code Source
77338 99226 NCCI
77338 99231 NCCI
77338 99232 NCCI
77338 99233 NCCI
77338 99234 NCCI
77338 99235 NCCI
77338 99236 NCCI
77338 99238 NCCI
77338 99239 NCCI
77338 99281 NCCI
77338 99282 NCCI
77338 99283 NCCI
77338 99284 NCCI
77338 99285 NCCI
77338 99291 NCCI
77338 99292 NCCI
77338 99304 NCCI
77338 99305 NCCI
77338 99306 NCCI
77338 99307 NCCI
77338 99308 NCCI
77338 99309 NCCI
77338 99310 NCCI
77338 99315 NCCI
77338 99316 NCCI
77338 99318 NCCI
77338 99324 NCCI
77338 99325 NCCI
77338 99326 NCCI
77338 99327 NCCI
77338 99328 NCCI
77338 99334 NCCI
77338 99335 NCCI
77338 99336 NCCI
77338 99337 NCCI
77338 99341 NCCI
77338 99342 NCCI
77338 99343 NCCI
77338 99344 NCCI
77338 99345 NCCI
77338 99347 NCCI
77338 99348 NCCI
77338 99349 NCCI
77338 99350 NCCI
77338 99354 NCCI
77338 99355 NCCI
77338 99356 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 90 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77338 99357 NCCI
77338 99360 NCCI
77338 99406 NCCI
77338 99407 NCCI
77338 99455 NCCI
77338 99456 NCCI
77338 99460 NCCI
77338 99461 NCCI
77338 99462 NCCI
77338 99463 NCCI
77338 99464 NCCI
77338 99465 NCCI
77338 99466 NCCI
77338 99467 NCCI
77338 99468 NCCI
77338 99469 NCCI
77338 99471 NCCI
77338 99472 NCCI
77338 99475 NCCI
77338 99476 NCCI
77338 99477 NCCI
77338 99478 NCCI
77338 99479 NCCI
77338 99480 NCCI
77338 99485 NCCI
77338 G0436 NCCI
77338 G0437 NCCI
77338 G0459 NCCI
77338 M0064 NCCI
77370 11920 NCCI
77370 11921 NCCI
77370 16000 NCCI
77370 16020 NCCI
77370 16025 NCCI
77370 16030 NCCI
77370 36000 NCCI
77370 36410 NCCI
77370 36425 NCCI
77370 51701 NCCI
77370 51702 NCCI
77370 51703 NCCI
77370 77370 BCBST
77370 90832 NCCI
77370 90833 NCCI
77370 90834 NCCI
77370 90836 NCCI
77370 90837 NCCI
Comprehensive ComponentCode Code Source
77370 90838 NCCI
77370 90839 NCCI
77370 90846 NCCI
77370 90847 NCCI
77370 96360 NCCI
77370 96361 NCCI
77370 96365 NCCI
77370 96366 NCCI
77370 96367 NCCI
77370 96368 NCCI
77370 97802 NCCI
77370 97803 NCCI
77370 97804 NCCI
77370 99143 NCCI
77370 99144 NCCI
77370 99145 NCCI
77370 99201 NCCI
77370 99202 NCCI
77370 99203 NCCI
77370 99204 NCCI
77370 99205 NCCI
77370 99211 NCCI
77370 99212 NCCI
77370 99213 NCCI
77370 99214 NCCI
77370 99215 NCCI
77370 99217 NCCI
77370 99218 NCCI
77370 99219 NCCI
77370 99220 NCCI
77370 99221 NCCI
77370 99222 NCCI
77370 99223 NCCI
77370 99224 NCCI
77370 99225 NCCI
77370 99226 NCCI
77370 99231 NCCI
77370 99232 NCCI
77370 99233 NCCI
77370 99234 NCCI
77370 99235 NCCI
77370 99236 NCCI
77370 99238 NCCI
77370 99239 NCCI
77370 99281 NCCI
77370 99282 NCCI
77370 99283 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 91 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77370 99284 NCCI
77370 99285 NCCI
77370 99291 NCCI
77370 99292 NCCI
77370 99304 NCCI
77370 99305 NCCI
77370 99306 NCCI
77370 99307 NCCI
77370 99308 NCCI
77370 99309 NCCI
77370 99310 NCCI
77370 99315 NCCI
77370 99316 NCCI
77370 99318 NCCI
77370 99324 NCCI
77370 99325 NCCI
77370 99326 NCCI
77370 99327 NCCI
77370 99328 NCCI
77370 99334 NCCI
77370 99335 NCCI
77370 99336 NCCI
77370 99337 NCCI
77370 99341 NCCI
77370 99342 NCCI
77370 99343 NCCI
77370 99344 NCCI
77370 99345 NCCI
77370 99347 NCCI
77370 99348 NCCI
77370 99349 NCCI
77370 99350 NCCI
77370 99354 NCCI
77370 99355 NCCI
77370 99356 NCCI
77370 99357 NCCI
77370 99360 NCCI
77370 99455 NCCI
77370 99456 NCCI
77370 99460 NCCI
77370 99461 NCCI
77370 99462 NCCI
77370 99463 NCCI
77370 99464 NCCI
77370 99465 NCCI
77370 99466 NCCI
77370 99467 NCCI
Comprehensive ComponentCode Code Source
77370 99468 NCCI
77370 99469 NCCI
77370 99471 NCCI
77370 99472 NCCI
77370 99475 NCCI
77370 99476 NCCI
77370 99477 NCCI
77370 99478 NCCI
77370 99479 NCCI
77370 99480 NCCI
77370 99485 NCCI
77370 G0459 NCCI
77370 M0064 NCCI
77371 0197T NCCI
77371 11920 NCCI
77371 11921 NCCI
77371 16000 NCCI
77371 16020 NCCI
77371 16025 NCCI
77371 16030 NCCI
77371 20660 NCCI
77371 20661 NCCI
77371 20693 NCCI
77371 20694 NCCI
77371 36000 NCCI
77371 36410 NCCI
77371 36425 NCCI
77371 51701 NCCI
77371 51702 NCCI
77371 51703 NCCI
77371 61720 NCCI
77371 61781 NCCI
77371 61782 NCCI
77371 61783 NCCI
77371 61790 NCCI
77371 61791 NCCI
77371 69990 NCCI
77371 76950 NCCI
77371 77014 NCCI
77371 77305 NCCI
77371 77310 NCCI
77371 77315 NCCI
77371 77326 NCCI
77371 77327 NCCI
77371 77328 NCCI
77371 77332 NCCI
77371 77333 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 92 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77371 77372 NCCI
77371 77401 NCCI
77371 77402 NCCI
77371 77403 NCCI
77371 77404 NCCI
77371 77406 NCCI
77371 77407 NCCI
77371 77408 NCCI
77371 77409 NCCI
77371 77411 NCCI
77371 77412 NCCI
77371 77413 NCCI
77371 77414 NCCI
77371 77416 NCCI
77371 77421 NCCI
77371 77422 NCCI
77371 77423 NCCI
77371 77427 NCCI
77371 77431 NCCI
77371 77435 NCCI
77371 77469 NCCI
77371 77470 NCCI
77371 90832 NCCI
77371 90833 NCCI
77371 90834 NCCI
77371 90836 NCCI
77371 90837 NCCI
77371 90838 NCCI
77371 90839 NCCI
77371 90846 NCCI
77371 90847 NCCI
77371 96360 NCCI
77371 96361 NCCI
77371 96365 NCCI
77371 96366 NCCI
77371 96367 NCCI
77371 96368 NCCI
77371 97802 NCCI
77371 97803 NCCI
77371 97804 NCCI
77371 99143 NCCI
77371 99144 NCCI
77371 99145 NCCI
77371 99148 NCCI
77371 99149 NCCI
77371 99150 NCCI
77371 99201 NCCI
Comprehensive ComponentCode Code Source
77371 99202 NCCI
77371 99203 NCCI
77371 99204 NCCI
77371 99205 NCCI
77371 99211 NCCI
77371 99212 NCCI
77371 99213 NCCI
77371 99214 NCCI
77371 99215 NCCI
77371 99217 NCCI
77371 99218 NCCI
77371 99219 NCCI
77371 99220 NCCI
77371 99221 NCCI
77371 99222 NCCI
77371 99223 NCCI
77371 99224 NCCI
77371 99225 NCCI
77371 99226 NCCI
77371 99231 NCCI
77371 99232 NCCI
77371 99233 NCCI
77371 99234 NCCI
77371 99235 NCCI
77371 99236 NCCI
77371 99238 NCCI
77371 99239 NCCI
77371 99281 NCCI
77371 99282 NCCI
77371 99283 NCCI
77371 99284 NCCI
77371 99285 NCCI
77371 99291 NCCI
77371 99304 NCCI
77371 99305 NCCI
77371 99306 NCCI
77371 99307 NCCI
77371 99308 NCCI
77371 99309 NCCI
77371 99310 NCCI
77371 99315 NCCI
77371 99316 NCCI
77371 99318 NCCI
77371 99324 NCCI
77371 99325 NCCI
77371 99326 NCCI
77371 99327 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 93 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77371 99328 NCCI
77371 99334 NCCI
77371 99335 NCCI
77371 99336 NCCI
77371 99337 NCCI
77371 99341 NCCI
77371 99342 NCCI
77371 99343 NCCI
77371 99344 NCCI
77371 99345 NCCI
77371 99347 NCCI
77371 99348 NCCI
77371 99349 NCCI
77371 99350 NCCI
77371 99354 NCCI
77371 99355 NCCI
77371 99356 NCCI
77371 99357 NCCI
77371 99360 NCCI
77371 99455 NCCI
77371 99456 NCCI
77371 99460 NCCI
77371 99461 NCCI
77371 99462 NCCI
77371 99463 NCCI
77371 99464 NCCI
77371 99465 NCCI
77371 99466 NCCI
77371 99468 NCCI
77371 99469 NCCI
77371 99471 NCCI
77371 99472 NCCI
77371 99475 NCCI
77371 99476 NCCI
77371 99477 NCCI
77371 99478 NCCI
77371 99479 NCCI
77371 99480 NCCI
77371 99485 NCCI
77371 G0251 NCCI
77371 G0339 NCCI
77371 G0340 NCCI
77371 G0459 NCCI
77371 M0064 NCCI
77372 0197T NCCI
77372 11920 NCCI
77372 11921 NCCI
Comprehensive ComponentCode Code Source
77372 16000 NCCI
77372 16020 NCCI
77372 16025 NCCI
77372 16030 NCCI
77372 20660 NCCI
77372 20661 NCCI
77372 20693 NCCI
77372 20694 NCCI
77372 36000 NCCI
77372 36410 NCCI
77372 36425 NCCI
77372 51701 NCCI
77372 51702 NCCI
77372 51703 NCCI
77372 61781 NCCI
77372 61782 NCCI
77372 61783 NCCI
77372 61790 NCCI
77372 69990 NCCI
77372 76950 NCCI
77372 77014 NCCI
77372 77305 NCCI
77372 77310 NCCI
77372 77315 NCCI
77372 77326 NCCI
77372 77327 NCCI
77372 77328 NCCI
77372 77332 NCCI
77372 77333 NCCI
77372 77401 NCCI
77372 77402 NCCI
77372 77403 NCCI
77372 77404 NCCI
77372 77406 NCCI
77372 77407 NCCI
77372 77408 NCCI
77372 77409 NCCI
77372 77411 NCCI
77372 77412 NCCI
77372 77413 NCCI
77372 77414 NCCI
77372 77416 NCCI
77372 77421 NCCI
77372 77422 NCCI
77372 77423 NCCI
77372 77427 NCCI
77372 77431 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 94 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77372 77435 NCCI
77372 77469 NCCI
77372 77470 NCCI
77372 90832 NCCI
77372 90833 NCCI
77372 90834 NCCI
77372 90836 NCCI
77372 90837 NCCI
77372 90838 NCCI
77372 90839 NCCI
77372 90846 NCCI
77372 90847 NCCI
77372 96360 NCCI
77372 96361 NCCI
77372 96365 NCCI
77372 96366 NCCI
77372 96367 NCCI
77372 96368 NCCI
77372 97802 NCCI
77372 97803 NCCI
77372 97804 NCCI
77372 99143 NCCI
77372 99144 NCCI
77372 99145 NCCI
77372 99201 NCCI
77372 99202 NCCI
77372 99203 NCCI
77372 99204 NCCI
77372 99205 NCCI
77372 99211 NCCI
77372 99212 NCCI
77372 99213 NCCI
77372 99214 NCCI
77372 99215 NCCI
77372 99217 NCCI
77372 99218 NCCI
77372 99219 NCCI
77372 99220 NCCI
77372 99221 NCCI
77372 99222 NCCI
77372 99223 NCCI
77372 99224 NCCI
77372 99225 NCCI
77372 99226 NCCI
77372 99231 NCCI
77372 99232 NCCI
77372 99233 NCCI
Comprehensive ComponentCode Code Source
77372 99234 NCCI
77372 99235 NCCI
77372 99236 NCCI
77372 99238 NCCI
77372 99239 NCCI
77372 99281 NCCI
77372 99282 NCCI
77372 99283 NCCI
77372 99284 NCCI
77372 99285 NCCI
77372 99291 NCCI
77372 99304 NCCI
77372 99305 NCCI
77372 99306 NCCI
77372 99307 NCCI
77372 99308 NCCI
77372 99309 NCCI
77372 99310 NCCI
77372 99315 NCCI
77372 99316 NCCI
77372 99318 NCCI
77372 99324 NCCI
77372 99325 NCCI
77372 99326 NCCI
77372 99327 NCCI
77372 99328 NCCI
77372 99334 NCCI
77372 99335 NCCI
77372 99336 NCCI
77372 99337 NCCI
77372 99341 NCCI
77372 99342 NCCI
77372 99343 NCCI
77372 99344 NCCI
77372 99345 NCCI
77372 99347 NCCI
77372 99348 NCCI
77372 99349 NCCI
77372 99350 NCCI
77372 99354 NCCI
77372 99355 NCCI
77372 99356 NCCI
77372 99357 NCCI
77372 99360 NCCI
77372 99455 NCCI
77372 99456 NCCI
77372 99460 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 95 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77372 99461 NCCI
77372 99462 NCCI
77372 99463 NCCI
77372 99464 NCCI
77372 99465 NCCI
77372 99466 NCCI
77372 99468 NCCI
77372 99469 NCCI
77372 99471 NCCI
77372 99472 NCCI
77372 99475 NCCI
77372 99476 NCCI
77372 99477 NCCI
77372 99478 NCCI
77372 99479 NCCI
77372 99480 NCCI
77372 99485 NCCI
77372 G0251 NCCI
77372 G0339 NCCI
77372 G0340 NCCI
77372 G0459 NCCI
77372 M0064 NCCI
77373 0197T NCCI
77373 11920 NCCI
77373 11921 NCCI
77373 16000 NCCI
77373 16020 NCCI
77373 16025 NCCI
77373 16030 NCCI
77373 20660 NCCI
77373 20661 NCCI
77373 20693 NCCI
77373 20694 NCCI
77373 36000 NCCI
77373 36410 NCCI
77373 36425 NCCI
77373 51701 NCCI
77373 51702 NCCI
77373 51703 NCCI
77373 61720 NCCI
77373 61735 NCCI
77373 61781 NCCI
77373 61782 NCCI
77373 61783 NCCI
77373 61790 NCCI
77373 61791 NCCI
77373 69990 NCCI
Comprehensive ComponentCode Code Source
77373 76950 NCCI
77373 77014 NCCI
77373 77305 NCCI
77373 77310 NCCI
77373 77315 NCCI
77373 77326 NCCI
77373 77327 NCCI
77373 77328 NCCI
77373 77332 NCCI
77373 77333 NCCI
77373 77371 NCCI
77373 77372 NCCI
77373 77401 NCCI
77373 77402 NCCI
77373 77403 NCCI
77373 77404 NCCI
77373 77406 NCCI
77373 77407 NCCI
77373 77408 NCCI
77373 77409 NCCI
77373 77411 NCCI
77373 77412 NCCI
77373 77413 NCCI
77373 77414 NCCI
77373 77416 NCCI
77373 77421 NCCI
77373 77422 NCCI
77373 77423 NCCI
77373 77427 NCCI
77373 77431 NCCI
77373 77432 NCCI
77373 77469 NCCI
77373 77470 NCCI
77373 90832 NCCI
77373 90833 NCCI
77373 90834 NCCI
77373 90836 NCCI
77373 90837 NCCI
77373 90838 NCCI
77373 90839 NCCI
77373 90846 NCCI
77373 90847 NCCI
77373 96360 NCCI
77373 96361 NCCI
77373 96365 NCCI
77373 96366 NCCI
77373 96367 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 96 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77373 96368 NCCI
77373 97802 NCCI
77373 97803 NCCI
77373 97804 NCCI
77373 99143 NCCI
77373 99144 NCCI
77373 99145 NCCI
77373 99201 NCCI
77373 99202 NCCI
77373 99203 NCCI
77373 99204 NCCI
77373 99205 NCCI
77373 99211 NCCI
77373 99212 NCCI
77373 99213 NCCI
77373 99214 NCCI
77373 99215 NCCI
77373 99217 NCCI
77373 99218 NCCI
77373 99219 NCCI
77373 99220 NCCI
77373 99221 NCCI
77373 99222 NCCI
77373 99223 NCCI
77373 99224 NCCI
77373 99225 NCCI
77373 99226 NCCI
77373 99231 NCCI
77373 99232 NCCI
77373 99233 NCCI
77373 99234 NCCI
77373 99235 NCCI
77373 99236 NCCI
77373 99238 NCCI
77373 99239 NCCI
77373 99281 NCCI
77373 99282 NCCI
77373 99283 NCCI
77373 99284 NCCI
77373 99285 NCCI
77373 99291 NCCI
77373 99304 NCCI
77373 99305 NCCI
77373 99306 NCCI
77373 99307 NCCI
77373 99308 NCCI
77373 99309 NCCI
Comprehensive ComponentCode Code Source
77373 99310 NCCI
77373 99315 NCCI
77373 99316 NCCI
77373 99318 NCCI
77373 99324 NCCI
77373 99325 NCCI
77373 99326 NCCI
77373 99327 NCCI
77373 99328 NCCI
77373 99334 NCCI
77373 99335 NCCI
77373 99336 NCCI
77373 99337 NCCI
77373 99341 NCCI
77373 99342 NCCI
77373 99343 NCCI
77373 99344 NCCI
77373 99345 NCCI
77373 99347 NCCI
77373 99348 NCCI
77373 99349 NCCI
77373 99350 NCCI
77373 99354 NCCI
77373 99355 NCCI
77373 99356 NCCI
77373 99357 NCCI
77373 99360 NCCI
77373 99455 NCCI
77373 99456 NCCI
77373 99460 NCCI
77373 99461 NCCI
77373 99462 NCCI
77373 99463 NCCI
77373 99464 NCCI
77373 99465 NCCI
77373 99466 NCCI
77373 99468 NCCI
77373 99469 NCCI
77373 99471 NCCI
77373 99472 NCCI
77373 99475 NCCI
77373 99476 NCCI
77373 99477 NCCI
77373 99478 NCCI
77373 99479 NCCI
77373 99480 NCCI
77373 99485 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 97 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77373 G0251 NCCI
77373 G0339 NCCI
77373 G0340 NCCI
77373 G0459 NCCI
77373 M0064 NCCI
77401 11920 NCCI
77401 11921 NCCI
77401 16000 NCCI
77401 16020 NCCI
77401 16025 NCCI
77401 16030 NCCI
77401 36000 NCCI
77401 36410 NCCI
77401 36425 NCCI
77401 51701 NCCI
77401 51702 NCCI
77401 51703 NCCI
77401 76376 NCCI
77401 76377 NCCI
77401 77422 NCCI
77401 90832 NCCI
77401 90833 NCCI
77401 90834 NCCI
77401 90836 NCCI
77401 90837 NCCI
77401 90838 NCCI
77401 90839 NCCI
77401 90846 NCCI
77401 90847 NCCI
77401 96360 NCCI
77401 96361 NCCI
77401 96365 NCCI
77401 96366 NCCI
77401 96367 NCCI
77401 96368 NCCI
77401 97802 NCCI
77401 97803 NCCI
77401 97804 NCCI
77401 99143 NCCI
77401 99144 NCCI
77401 99145 NCCI
77401 99201 NCCI
77401 99202 NCCI
77401 99203 NCCI
77401 99204 NCCI
77401 99205 NCCI
77401 99211 NCCI
Comprehensive ComponentCode Code Source
77401 99212 NCCI
77401 99213 NCCI
77401 99214 NCCI
77401 99215 NCCI
77401 99217 NCCI
77401 99218 NCCI
77401 99219 NCCI
77401 99220 NCCI
77401 99221 NCCI
77401 99222 NCCI
77401 99223 NCCI
77401 99224 NCCI
77401 99225 NCCI
77401 99226 NCCI
77401 99231 NCCI
77401 99232 NCCI
77401 99233 NCCI
77401 99234 NCCI
77401 99235 NCCI
77401 99236 NCCI
77401 99238 NCCI
77401 99239 NCCI
77401 99281 NCCI
77401 99282 NCCI
77401 99283 NCCI
77401 99284 NCCI
77401 99285 NCCI
77401 99291 NCCI
77401 99292 NCCI
77401 99304 NCCI
77401 99305 NCCI
77401 99306 NCCI
77401 99307 NCCI
77401 99308 NCCI
77401 99309 NCCI
77401 99310 NCCI
77401 99315 NCCI
77401 99316 NCCI
77401 99318 NCCI
77401 99324 NCCI
77401 99325 NCCI
77401 99326 NCCI
77401 99327 NCCI
77401 99328 NCCI
77401 99334 NCCI
77401 99335 NCCI
77401 99336 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 98 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77401 99337 NCCI
77401 99341 NCCI
77401 99342 NCCI
77401 99343 NCCI
77401 99344 NCCI
77401 99345 NCCI
77401 99347 NCCI
77401 99348 NCCI
77401 99349 NCCI
77401 99350 NCCI
77401 99354 NCCI
77401 99355 NCCI
77401 99356 NCCI
77401 99357 NCCI
77401 99360 NCCI
77401 99455 NCCI
77401 99456 NCCI
77401 99460 NCCI
77401 99461 NCCI
77401 99462 NCCI
77401 99463 NCCI
77401 99464 NCCI
77401 99465 NCCI
77401 99466 NCCI
77401 99467 NCCI
77401 99468 NCCI
77401 99469 NCCI
77401 99471 NCCI
77401 99472 NCCI
77401 99475 NCCI
77401 99476 NCCI
77401 99477 NCCI
77401 99478 NCCI
77401 99479 NCCI
77401 99480 NCCI
77401 99485 NCCI
77401 G0459 NCCI
77401 M0064 NCCI
77402 11920 NCCI
77402 11921 NCCI
77402 16000 NCCI
77402 16020 NCCI
77402 16025 NCCI
77402 16030 NCCI
77402 36000 NCCI
77402 36410 NCCI
77402 36425 NCCI
Comprehensive ComponentCode Code Source
77402 51701 NCCI
77402 51702 NCCI
77402 51703 NCCI
77402 76376 NCCI
77402 76377 NCCI
77402 77401 NCCI
77402 77422 NCCI
77402 90832 NCCI
77402 90833 NCCI
77402 90834 NCCI
77402 90836 NCCI
77402 90837 NCCI
77402 90838 NCCI
77402 90839 NCCI
77402 90846 NCCI
77402 90847 NCCI
77402 96360 NCCI
77402 96361 NCCI
77402 96365 NCCI
77402 96366 NCCI
77402 96367 NCCI
77402 96368 NCCI
77402 97802 NCCI
77402 97803 NCCI
77402 97804 NCCI
77402 99143 NCCI
77402 99144 NCCI
77402 99145 NCCI
77402 99201 NCCI
77402 99202 NCCI
77402 99203 NCCI
77402 99204 NCCI
77402 99205 NCCI
77402 99211 NCCI
77402 99212 NCCI
77402 99213 NCCI
77402 99214 NCCI
77402 99215 NCCI
77402 99217 NCCI
77402 99218 NCCI
77402 99219 NCCI
77402 99220 NCCI
77402 99221 NCCI
77402 99222 NCCI
77402 99223 NCCI
77402 99224 NCCI
77402 99225 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 99 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77402 99226 NCCI
77402 99231 NCCI
77402 99232 NCCI
77402 99233 NCCI
77402 99234 NCCI
77402 99235 NCCI
77402 99236 NCCI
77402 99238 NCCI
77402 99239 NCCI
77402 99281 NCCI
77402 99282 NCCI
77402 99283 NCCI
77402 99284 NCCI
77402 99285 NCCI
77402 99291 NCCI
77402 99292 NCCI
77402 99304 NCCI
77402 99305 NCCI
77402 99306 NCCI
77402 99307 NCCI
77402 99308 NCCI
77402 99309 NCCI
77402 99310 NCCI
77402 99315 NCCI
77402 99316 NCCI
77402 99318 NCCI
77402 99324 NCCI
77402 99325 NCCI
77402 99326 NCCI
77402 99327 NCCI
77402 99328 NCCI
77402 99334 NCCI
77402 99335 NCCI
77402 99336 NCCI
77402 99337 NCCI
77402 99341 NCCI
77402 99342 NCCI
77402 99343 NCCI
77402 99344 NCCI
77402 99345 NCCI
77402 99347 NCCI
77402 99348 NCCI
77402 99349 NCCI
77402 99350 NCCI
77402 99354 NCCI
77402 99355 NCCI
77402 99356 NCCI
Comprehensive ComponentCode Code Source
77402 99357 NCCI
77402 99360 NCCI
77402 99455 NCCI
77402 99456 NCCI
77402 99460 NCCI
77402 99461 NCCI
77402 99462 NCCI
77402 99463 NCCI
77402 99464 NCCI
77402 99465 NCCI
77402 99466 NCCI
77402 99467 NCCI
77402 99468 NCCI
77402 99469 NCCI
77402 99471 NCCI
77402 99472 NCCI
77402 99475 NCCI
77402 99476 NCCI
77402 99477 NCCI
77402 99478 NCCI
77402 99479 NCCI
77402 99480 NCCI
77402 99485 NCCI
77402 G0459 NCCI
77402 M0064 NCCI
77403 11920 NCCI
77403 11921 NCCI
77403 16000 NCCI
77403 16020 NCCI
77403 16025 NCCI
77403 16030 NCCI
77403 36000 NCCI
77403 36410 NCCI
77403 36425 NCCI
77403 51701 NCCI
77403 51702 NCCI
77403 51703 NCCI
77403 76376 NCCI
77403 76377 NCCI
77403 77401 NCCI
77403 77402 NCCI
77403 77422 NCCI
77403 90832 NCCI
77403 90833 NCCI
77403 90834 NCCI
77403 90836 NCCI
77403 90837 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 100 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77403 90838 NCCI
77403 90839 NCCI
77403 90846 NCCI
77403 90847 NCCI
77403 96360 NCCI
77403 96361 NCCI
77403 96365 NCCI
77403 96366 NCCI
77403 96367 NCCI
77403 96368 NCCI
77403 97802 NCCI
77403 97803 NCCI
77403 97804 NCCI
77403 99143 NCCI
77403 99144 NCCI
77403 99145 NCCI
77403 99201 NCCI
77403 99202 NCCI
77403 99203 NCCI
77403 99204 NCCI
77403 99205 NCCI
77403 99211 NCCI
77403 99212 NCCI
77403 99213 NCCI
77403 99214 NCCI
77403 99215 NCCI
77403 99217 NCCI
77403 99218 NCCI
77403 99219 NCCI
77403 99220 NCCI
77403 99221 NCCI
77403 99222 NCCI
77403 99223 NCCI
77403 99224 NCCI
77403 99225 NCCI
77403 99226 NCCI
77403 99231 NCCI
77403 99232 NCCI
77403 99233 NCCI
77403 99234 NCCI
77403 99235 NCCI
77403 99236 NCCI
77403 99238 NCCI
77403 99239 NCCI
77403 99281 NCCI
77403 99282 NCCI
77403 99283 NCCI
Comprehensive ComponentCode Code Source
77403 99284 NCCI
77403 99285 NCCI
77403 99291 NCCI
77403 99292 NCCI
77403 99304 NCCI
77403 99305 NCCI
77403 99306 NCCI
77403 99307 NCCI
77403 99308 NCCI
77403 99309 NCCI
77403 99310 NCCI
77403 99315 NCCI
77403 99316 NCCI
77403 99318 NCCI
77403 99324 NCCI
77403 99325 NCCI
77403 99326 NCCI
77403 99327 NCCI
77403 99328 NCCI
77403 99334 NCCI
77403 99335 NCCI
77403 99336 NCCI
77403 99337 NCCI
77403 99341 NCCI
77403 99342 NCCI
77403 99343 NCCI
77403 99344 NCCI
77403 99345 NCCI
77403 99347 NCCI
77403 99348 NCCI
77403 99349 NCCI
77403 99350 NCCI
77403 99354 NCCI
77403 99355 NCCI
77403 99356 NCCI
77403 99357 NCCI
77403 99360 NCCI
77403 99455 NCCI
77403 99456 NCCI
77403 99460 NCCI
77403 99461 NCCI
77403 99462 NCCI
77403 99463 NCCI
77403 99464 NCCI
77403 99465 NCCI
77403 99466 NCCI
77403 99467 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 101 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77403 99468 NCCI
77403 99469 NCCI
77403 99471 NCCI
77403 99472 NCCI
77403 99475 NCCI
77403 99476 NCCI
77403 99477 NCCI
77403 99478 NCCI
77403 99479 NCCI
77403 99480 NCCI
77403 99485 NCCI
77403 G0459 NCCI
77403 M0064 NCCI
77404 11920 NCCI
77404 11921 NCCI
77404 16000 NCCI
77404 16020 NCCI
77404 16025 NCCI
77404 16030 NCCI
77404 36000 NCCI
77404 36410 NCCI
77404 36425 NCCI
77404 51701 NCCI
77404 51702 NCCI
77404 51703 NCCI
77404 76376 NCCI
77404 76377 NCCI
77404 77401 NCCI
77404 77402 NCCI
77404 77403 NCCI
77404 77422 NCCI
77404 90832 NCCI
77404 90833 NCCI
77404 90834 NCCI
77404 90836 NCCI
77404 90837 NCCI
77404 90838 NCCI
77404 90839 NCCI
77404 90846 NCCI
77404 90847 NCCI
77404 96360 NCCI
77404 96361 NCCI
77404 96365 NCCI
77404 96366 NCCI
77404 96367 NCCI
77404 96368 NCCI
77404 97802 NCCI
Comprehensive ComponentCode Code Source
77404 97803 NCCI
77404 97804 NCCI
77404 99143 NCCI
77404 99144 NCCI
77404 99145 NCCI
77404 99201 NCCI
77404 99202 NCCI
77404 99203 NCCI
77404 99204 NCCI
77404 99205 NCCI
77404 99211 NCCI
77404 99212 NCCI
77404 99213 NCCI
77404 99214 NCCI
77404 99215 NCCI
77404 99217 NCCI
77404 99218 NCCI
77404 99219 NCCI
77404 99220 NCCI
77404 99221 NCCI
77404 99222 NCCI
77404 99223 NCCI
77404 99224 NCCI
77404 99225 NCCI
77404 99226 NCCI
77404 99231 NCCI
77404 99232 NCCI
77404 99233 NCCI
77404 99234 NCCI
77404 99235 NCCI
77404 99236 NCCI
77404 99238 NCCI
77404 99239 NCCI
77404 99281 NCCI
77404 99282 NCCI
77404 99283 NCCI
77404 99284 NCCI
77404 99285 NCCI
77404 99291 NCCI
77404 99292 NCCI
77404 99304 NCCI
77404 99305 NCCI
77404 99306 NCCI
77404 99307 NCCI
77404 99308 NCCI
77404 99309 NCCI
77404 99310 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 102 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77404 99315 NCCI
77404 99316 NCCI
77404 99318 NCCI
77404 99324 NCCI
77404 99325 NCCI
77404 99326 NCCI
77404 99327 NCCI
77404 99328 NCCI
77404 99334 NCCI
77404 99335 NCCI
77404 99336 NCCI
77404 99337 NCCI
77404 99341 NCCI
77404 99342 NCCI
77404 99343 NCCI
77404 99344 NCCI
77404 99345 NCCI
77404 99347 NCCI
77404 99348 NCCI
77404 99349 NCCI
77404 99350 NCCI
77404 99354 NCCI
77404 99355 NCCI
77404 99356 NCCI
77404 99357 NCCI
77404 99360 NCCI
77404 99455 NCCI
77404 99456 NCCI
77404 99460 NCCI
77404 99461 NCCI
77404 99462 NCCI
77404 99463 NCCI
77404 99464 NCCI
77404 99465 NCCI
77404 99466 NCCI
77404 99467 NCCI
77404 99468 NCCI
77404 99469 NCCI
77404 99471 NCCI
77404 99472 NCCI
77404 99475 NCCI
77404 99476 NCCI
77404 99477 NCCI
77404 99478 NCCI
77404 99479 NCCI
77404 99480 NCCI
77404 99485 NCCI
Comprehensive ComponentCode Code Source
77404 G0459 NCCI
77404 M0064 NCCI
77406 11920 NCCI
77406 11921 NCCI
77406 16000 NCCI
77406 16020 NCCI
77406 16025 NCCI
77406 16030 NCCI
77406 36000 NCCI
77406 36410 NCCI
77406 36425 NCCI
77406 51701 NCCI
77406 51702 NCCI
77406 51703 NCCI
77406 76376 NCCI
77406 76377 NCCI
77406 77401 NCCI
77406 77402 NCCI
77406 77403 NCCI
77406 77404 NCCI
77406 77422 NCCI
77406 90832 NCCI
77406 90833 NCCI
77406 90834 NCCI
77406 90836 NCCI
77406 90837 NCCI
77406 90838 NCCI
77406 90839 NCCI
77406 90846 NCCI
77406 90847 NCCI
77406 96360 NCCI
77406 96361 NCCI
77406 96365 NCCI
77406 96366 NCCI
77406 96367 NCCI
77406 96368 NCCI
77406 97802 NCCI
77406 97803 NCCI
77406 97804 NCCI
77406 99143 NCCI
77406 99144 NCCI
77406 99145 NCCI
77406 99201 NCCI
77406 99202 NCCI
77406 99203 NCCI
77406 99204 NCCI
77406 99205 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 103 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77406 99211 NCCI
77406 99212 NCCI
77406 99213 NCCI
77406 99214 NCCI
77406 99215 NCCI
77406 99217 NCCI
77406 99218 NCCI
77406 99219 NCCI
77406 99220 NCCI
77406 99221 NCCI
77406 99222 NCCI
77406 99223 NCCI
77406 99224 NCCI
77406 99225 NCCI
77406 99226 NCCI
77406 99231 NCCI
77406 99232 NCCI
77406 99233 NCCI
77406 99234 NCCI
77406 99235 NCCI
77406 99236 NCCI
77406 99238 NCCI
77406 99239 NCCI
77406 99281 NCCI
77406 99282 NCCI
77406 99283 NCCI
77406 99284 NCCI
77406 99285 NCCI
77406 99291 NCCI
77406 99292 NCCI
77406 99304 NCCI
77406 99305 NCCI
77406 99306 NCCI
77406 99307 NCCI
77406 99308 NCCI
77406 99309 NCCI
77406 99310 NCCI
77406 99315 NCCI
77406 99316 NCCI
77406 99318 NCCI
77406 99324 NCCI
77406 99325 NCCI
77406 99326 NCCI
77406 99327 NCCI
77406 99328 NCCI
77406 99334 NCCI
77406 99335 NCCI
Comprehensive ComponentCode Code Source
77406 99336 NCCI
77406 99337 NCCI
77406 99341 NCCI
77406 99342 NCCI
77406 99343 NCCI
77406 99344 NCCI
77406 99345 NCCI
77406 99347 NCCI
77406 99348 NCCI
77406 99349 NCCI
77406 99350 NCCI
77406 99354 NCCI
77406 99355 NCCI
77406 99356 NCCI
77406 99357 NCCI
77406 99360 NCCI
77406 99455 NCCI
77406 99456 NCCI
77406 99460 NCCI
77406 99461 NCCI
77406 99462 NCCI
77406 99463 NCCI
77406 99464 NCCI
77406 99465 NCCI
77406 99466 NCCI
77406 99467 NCCI
77406 99468 NCCI
77406 99469 NCCI
77406 99471 NCCI
77406 99472 NCCI
77406 99475 NCCI
77406 99476 NCCI
77406 99477 NCCI
77406 99478 NCCI
77406 99479 NCCI
77406 99480 NCCI
77406 99485 NCCI
77406 G0459 NCCI
77406 M0064 NCCI
77407 11920 NCCI
77407 11921 NCCI
77407 16000 NCCI
77407 16020 NCCI
77407 16025 NCCI
77407 16030 NCCI
77407 36000 NCCI
77407 36410 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 104 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77407 36425 NCCI
77407 51701 NCCI
77407 51702 NCCI
77407 51703 NCCI
77407 76376 NCCI
77407 76377 NCCI
77407 77401 NCCI
77407 77402 NCCI
77407 77403 NCCI
77407 77404 NCCI
77407 77406 NCCI
77407 77422 NCCI
77407 90832 NCCI
77407 90833 NCCI
77407 90834 NCCI
77407 90836 NCCI
77407 90837 NCCI
77407 90838 NCCI
77407 90839 NCCI
77407 90846 NCCI
77407 90847 NCCI
77407 96360 NCCI
77407 96361 NCCI
77407 96365 NCCI
77407 96366 NCCI
77407 96367 NCCI
77407 96368 NCCI
77407 97802 NCCI
77407 97803 NCCI
77407 97804 NCCI
77407 99143 NCCI
77407 99144 NCCI
77407 99145 NCCI
77407 99201 NCCI
77407 99202 NCCI
77407 99203 NCCI
77407 99204 NCCI
77407 99205 NCCI
77407 99211 NCCI
77407 99212 NCCI
77407 99213 NCCI
77407 99214 NCCI
77407 99215 NCCI
77407 99217 NCCI
77407 99218 NCCI
77407 99219 NCCI
77407 99220 NCCI
Comprehensive ComponentCode Code Source
77407 99221 NCCI
77407 99222 NCCI
77407 99223 NCCI
77407 99224 NCCI
77407 99225 NCCI
77407 99226 NCCI
77407 99231 NCCI
77407 99232 NCCI
77407 99233 NCCI
77407 99234 NCCI
77407 99235 NCCI
77407 99236 NCCI
77407 99238 NCCI
77407 99239 NCCI
77407 99281 NCCI
77407 99282 NCCI
77407 99283 NCCI
77407 99284 NCCI
77407 99285 NCCI
77407 99291 NCCI
77407 99292 NCCI
77407 99304 NCCI
77407 99305 NCCI
77407 99306 NCCI
77407 99307 NCCI
77407 99308 NCCI
77407 99309 NCCI
77407 99310 NCCI
77407 99315 NCCI
77407 99316 NCCI
77407 99318 NCCI
77407 99324 NCCI
77407 99325 NCCI
77407 99326 NCCI
77407 99327 NCCI
77407 99328 NCCI
77407 99334 NCCI
77407 99335 NCCI
77407 99336 NCCI
77407 99337 NCCI
77407 99341 NCCI
77407 99342 NCCI
77407 99343 NCCI
77407 99344 NCCI
77407 99345 NCCI
77407 99347 NCCI
77407 99348 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 105 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77407 99349 NCCI
77407 99350 NCCI
77407 99354 NCCI
77407 99355 NCCI
77407 99356 NCCI
77407 99357 NCCI
77407 99360 NCCI
77407 99455 NCCI
77407 99456 NCCI
77407 99460 NCCI
77407 99461 NCCI
77407 99462 NCCI
77407 99463 NCCI
77407 99464 NCCI
77407 99465 NCCI
77407 99466 NCCI
77407 99467 NCCI
77407 99468 NCCI
77407 99469 NCCI
77407 99471 NCCI
77407 99472 NCCI
77407 99475 NCCI
77407 99476 NCCI
77407 99477 NCCI
77407 99478 NCCI
77407 99479 NCCI
77407 99480 NCCI
77407 99485 NCCI
77407 G0459 NCCI
77407 M0064 NCCI
77408 11920 NCCI
77408 11921 NCCI
77408 16000 NCCI
77408 16020 NCCI
77408 16025 NCCI
77408 16030 NCCI
77408 36000 NCCI
77408 36410 NCCI
77408 36425 NCCI
77408 51701 NCCI
77408 51702 NCCI
77408 51703 NCCI
77408 76376 NCCI
77408 76377 NCCI
77408 77401 NCCI
77408 77402 NCCI
77408 77403 NCCI
Comprehensive ComponentCode Code Source
77408 77404 NCCI
77408 77406 NCCI
77408 77407 NCCI
77408 77422 NCCI
77408 90832 NCCI
77408 90833 NCCI
77408 90834 NCCI
77408 90836 NCCI
77408 90837 NCCI
77408 90838 NCCI
77408 90839 NCCI
77408 90846 NCCI
77408 90847 NCCI
77408 96360 NCCI
77408 96361 NCCI
77408 96365 NCCI
77408 96366 NCCI
77408 96367 NCCI
77408 96368 NCCI
77408 97802 NCCI
77408 97803 NCCI
77408 97804 NCCI
77408 99143 NCCI
77408 99144 NCCI
77408 99145 NCCI
77408 99201 NCCI
77408 99202 NCCI
77408 99203 NCCI
77408 99204 NCCI
77408 99205 NCCI
77408 99211 NCCI
77408 99212 NCCI
77408 99213 NCCI
77408 99214 NCCI
77408 99215 NCCI
77408 99217 NCCI
77408 99218 NCCI
77408 99219 NCCI
77408 99220 NCCI
77408 99221 NCCI
77408 99222 NCCI
77408 99223 NCCI
77408 99224 NCCI
77408 99225 NCCI
77408 99226 NCCI
77408 99231 NCCI
77408 99232 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 106 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77408 99233 NCCI
77408 99234 NCCI
77408 99235 NCCI
77408 99236 NCCI
77408 99238 NCCI
77408 99239 NCCI
77408 99281 NCCI
77408 99282 NCCI
77408 99283 NCCI
77408 99284 NCCI
77408 99285 NCCI
77408 99291 NCCI
77408 99292 NCCI
77408 99304 NCCI
77408 99305 NCCI
77408 99306 NCCI
77408 99307 NCCI
77408 99308 NCCI
77408 99309 NCCI
77408 99310 NCCI
77408 99315 NCCI
77408 99316 NCCI
77408 99318 NCCI
77408 99324 NCCI
77408 99325 NCCI
77408 99326 NCCI
77408 99327 NCCI
77408 99328 NCCI
77408 99334 NCCI
77408 99335 NCCI
77408 99336 NCCI
77408 99337 NCCI
77408 99341 NCCI
77408 99342 NCCI
77408 99343 NCCI
77408 99344 NCCI
77408 99345 NCCI
77408 99347 NCCI
77408 99348 NCCI
77408 99349 NCCI
77408 99350 NCCI
77408 99354 NCCI
77408 99355 NCCI
77408 99356 NCCI
77408 99357 NCCI
77408 99360 NCCI
77408 99455 NCCI
Comprehensive ComponentCode Code Source
77408 99456 NCCI
77408 99460 NCCI
77408 99461 NCCI
77408 99462 NCCI
77408 99463 NCCI
77408 99464 NCCI
77408 99465 NCCI
77408 99466 NCCI
77408 99467 NCCI
77408 99468 NCCI
77408 99469 NCCI
77408 99471 NCCI
77408 99472 NCCI
77408 99475 NCCI
77408 99476 NCCI
77408 99477 NCCI
77408 99478 NCCI
77408 99479 NCCI
77408 99480 NCCI
77408 99485 NCCI
77408 G0459 NCCI
77408 M0064 NCCI
77409 11920 NCCI
77409 11921 NCCI
77409 16000 NCCI
77409 16020 NCCI
77409 16025 NCCI
77409 16030 NCCI
77409 36000 NCCI
77409 36410 NCCI
77409 36425 NCCI
77409 51701 NCCI
77409 51702 NCCI
77409 51703 NCCI
77409 76376 NCCI
77409 76377 NCCI
77409 77401 NCCI
77409 77402 NCCI
77409 77403 NCCI
77409 77404 NCCI
77409 77406 NCCI
77409 77407 NCCI
77409 77408 NCCI
77409 77422 NCCI
77409 90832 NCCI
77409 90833 NCCI
77409 90834 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 107 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77409 90836 NCCI
77409 90837 NCCI
77409 90838 NCCI
77409 90839 NCCI
77409 90846 NCCI
77409 90847 NCCI
77409 96360 NCCI
77409 96361 NCCI
77409 96365 NCCI
77409 96366 NCCI
77409 96367 NCCI
77409 96368 NCCI
77409 97802 NCCI
77409 97803 NCCI
77409 97804 NCCI
77409 99143 NCCI
77409 99144 NCCI
77409 99145 NCCI
77409 99201 NCCI
77409 99202 NCCI
77409 99203 NCCI
77409 99204 NCCI
77409 99205 NCCI
77409 99211 NCCI
77409 99212 NCCI
77409 99213 NCCI
77409 99214 NCCI
77409 99215 NCCI
77409 99217 NCCI
77409 99218 NCCI
77409 99219 NCCI
77409 99220 NCCI
77409 99221 NCCI
77409 99222 NCCI
77409 99223 NCCI
77409 99224 NCCI
77409 99225 NCCI
77409 99226 NCCI
77409 99231 NCCI
77409 99232 NCCI
77409 99233 NCCI
77409 99234 NCCI
77409 99235 NCCI
77409 99236 NCCI
77409 99238 NCCI
77409 99239 NCCI
77409 99281 NCCI
Comprehensive ComponentCode Code Source
77409 99282 NCCI
77409 99283 NCCI
77409 99284 NCCI
77409 99285 NCCI
77409 99291 NCCI
77409 99292 NCCI
77409 99304 NCCI
77409 99305 NCCI
77409 99306 NCCI
77409 99307 NCCI
77409 99308 NCCI
77409 99309 NCCI
77409 99310 NCCI
77409 99315 NCCI
77409 99316 NCCI
77409 99318 NCCI
77409 99324 NCCI
77409 99325 NCCI
77409 99326 NCCI
77409 99327 NCCI
77409 99328 NCCI
77409 99334 NCCI
77409 99335 NCCI
77409 99336 NCCI
77409 99337 NCCI
77409 99341 NCCI
77409 99342 NCCI
77409 99343 NCCI
77409 99344 NCCI
77409 99345 NCCI
77409 99347 NCCI
77409 99348 NCCI
77409 99349 NCCI
77409 99350 NCCI
77409 99354 NCCI
77409 99355 NCCI
77409 99356 NCCI
77409 99357 NCCI
77409 99360 NCCI
77409 99455 NCCI
77409 99456 NCCI
77409 99460 NCCI
77409 99461 NCCI
77409 99462 NCCI
77409 99463 NCCI
77409 99464 NCCI
77409 99465 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 108 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77409 99466 NCCI
77409 99467 NCCI
77409 99468 NCCI
77409 99469 NCCI
77409 99471 NCCI
77409 99472 NCCI
77409 99475 NCCI
77409 99476 NCCI
77409 99477 NCCI
77409 99478 NCCI
77409 99479 NCCI
77409 99480 NCCI
77409 99485 NCCI
77409 G0459 NCCI
77409 M0064 NCCI
77411 11920 NCCI
77411 11921 NCCI
77411 16000 NCCI
77411 16020 NCCI
77411 16025 NCCI
77411 16030 NCCI
77411 36000 NCCI
77411 36410 NCCI
77411 36425 NCCI
77411 51701 NCCI
77411 51702 NCCI
77411 51703 NCCI
77411 76376 NCCI
77411 76377 NCCI
77411 77401 NCCI
77411 77402 NCCI
77411 77403 NCCI
77411 77404 NCCI
77411 77406 NCCI
77411 77407 NCCI
77411 77408 NCCI
77411 77409 NCCI
77411 77422 NCCI
77411 90832 NCCI
77411 90833 NCCI
77411 90834 NCCI
77411 90836 NCCI
77411 90837 NCCI
77411 90838 NCCI
77411 90839 NCCI
77411 90846 NCCI
77411 90847 NCCI
Comprehensive ComponentCode Code Source
77411 96360 NCCI
77411 96361 NCCI
77411 96365 NCCI
77411 96366 NCCI
77411 96367 NCCI
77411 96368 NCCI
77411 97802 NCCI
77411 97803 NCCI
77411 97804 NCCI
77411 99143 NCCI
77411 99144 NCCI
77411 99145 NCCI
77411 99201 NCCI
77411 99202 NCCI
77411 99203 NCCI
77411 99204 NCCI
77411 99205 NCCI
77411 99211 NCCI
77411 99212 NCCI
77411 99213 NCCI
77411 99214 NCCI
77411 99215 NCCI
77411 99217 NCCI
77411 99218 NCCI
77411 99219 NCCI
77411 99220 NCCI
77411 99221 NCCI
77411 99222 NCCI
77411 99223 NCCI
77411 99224 NCCI
77411 99225 NCCI
77411 99226 NCCI
77411 99231 NCCI
77411 99232 NCCI
77411 99233 NCCI
77411 99234 NCCI
77411 99235 NCCI
77411 99236 NCCI
77411 99238 NCCI
77411 99239 NCCI
77411 99281 NCCI
77411 99282 NCCI
77411 99283 NCCI
77411 99284 NCCI
77411 99285 NCCI
77411 99291 NCCI
77411 99292 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 109 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77411 99304 NCCI
77411 99305 NCCI
77411 99306 NCCI
77411 99307 NCCI
77411 99308 NCCI
77411 99309 NCCI
77411 99310 NCCI
77411 99315 NCCI
77411 99316 NCCI
77411 99318 NCCI
77411 99324 NCCI
77411 99325 NCCI
77411 99326 NCCI
77411 99327 NCCI
77411 99328 NCCI
77411 99334 NCCI
77411 99335 NCCI
77411 99336 NCCI
77411 99337 NCCI
77411 99341 NCCI
77411 99342 NCCI
77411 99343 NCCI
77411 99344 NCCI
77411 99345 NCCI
77411 99347 NCCI
77411 99348 NCCI
77411 99349 NCCI
77411 99350 NCCI
77411 99354 NCCI
77411 99355 NCCI
77411 99356 NCCI
77411 99357 NCCI
77411 99360 NCCI
77411 99455 NCCI
77411 99456 NCCI
77411 99460 NCCI
77411 99461 NCCI
77411 99462 NCCI
77411 99463 NCCI
77411 99464 NCCI
77411 99465 NCCI
77411 99466 NCCI
77411 99467 NCCI
77411 99468 NCCI
77411 99469 NCCI
77411 99471 NCCI
77411 99472 NCCI
Comprehensive ComponentCode Code Source
77411 99475 NCCI
77411 99476 NCCI
77411 99477 NCCI
77411 99478 NCCI
77411 99479 NCCI
77411 99480 NCCI
77411 99485 NCCI
77411 G0459 NCCI
77411 M0064 NCCI
77412 11920 NCCI
77412 11921 NCCI
77412 16000 NCCI
77412 16020 NCCI
77412 16025 NCCI
77412 16030 NCCI
77412 36000 NCCI
77412 36410 NCCI
77412 36425 NCCI
77412 51701 NCCI
77412 51702 NCCI
77412 51703 NCCI
77412 76376 NCCI
77412 76377 NCCI
77412 77401 NCCI
77412 77402 NCCI
77412 77403 NCCI
77412 77404 NCCI
77412 77406 NCCI
77412 77407 NCCI
77412 77408 NCCI
77412 77409 NCCI
77412 77411 NCCI
77412 77422 NCCI
77412 77423 NCCI
77412 90832 NCCI
77412 90833 NCCI
77412 90834 NCCI
77412 90836 NCCI
77412 90837 NCCI
77412 90838 NCCI
77412 90839 NCCI
77412 90846 NCCI
77412 90847 NCCI
77412 96360 NCCI
77412 96361 NCCI
77412 96365 NCCI
77412 96366 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 110 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77412 96367 NCCI
77412 96368 NCCI
77412 97802 NCCI
77412 97803 NCCI
77412 97804 NCCI
77412 99143 NCCI
77412 99144 NCCI
77412 99145 NCCI
77412 99201 NCCI
77412 99202 NCCI
77412 99203 NCCI
77412 99204 NCCI
77412 99205 NCCI
77412 99211 NCCI
77412 99212 NCCI
77412 99213 NCCI
77412 99214 NCCI
77412 99215 NCCI
77412 99217 NCCI
77412 99218 NCCI
77412 99219 NCCI
77412 99220 NCCI
77412 99221 NCCI
77412 99222 NCCI
77412 99223 NCCI
77412 99224 NCCI
77412 99225 NCCI
77412 99226 NCCI
77412 99231 NCCI
77412 99232 NCCI
77412 99233 NCCI
77412 99234 NCCI
77412 99235 NCCI
77412 99236 NCCI
77412 99238 NCCI
77412 99239 NCCI
77412 99281 NCCI
77412 99282 NCCI
77412 99283 NCCI
77412 99284 NCCI
77412 99285 NCCI
77412 99291 NCCI
77412 99292 NCCI
77412 99304 NCCI
77412 99305 NCCI
77412 99306 NCCI
77412 99307 NCCI
Comprehensive ComponentCode Code Source
77412 99308 NCCI
77412 99309 NCCI
77412 99310 NCCI
77412 99315 NCCI
77412 99316 NCCI
77412 99318 NCCI
77412 99324 NCCI
77412 99325 NCCI
77412 99326 NCCI
77412 99327 NCCI
77412 99328 NCCI
77412 99334 NCCI
77412 99335 NCCI
77412 99336 NCCI
77412 99337 NCCI
77412 99341 NCCI
77412 99342 NCCI
77412 99343 NCCI
77412 99344 NCCI
77412 99345 NCCI
77412 99347 NCCI
77412 99348 NCCI
77412 99349 NCCI
77412 99350 NCCI
77412 99354 NCCI
77412 99355 NCCI
77412 99356 NCCI
77412 99357 NCCI
77412 99360 NCCI
77412 99455 NCCI
77412 99456 NCCI
77412 99460 NCCI
77412 99461 NCCI
77412 99462 NCCI
77412 99463 NCCI
77412 99464 NCCI
77412 99465 NCCI
77412 99466 NCCI
77412 99467 NCCI
77412 99468 NCCI
77412 99469 NCCI
77412 99471 NCCI
77412 99472 NCCI
77412 99475 NCCI
77412 99476 NCCI
77412 99477 NCCI
77412 99478 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 111 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77412 99479 NCCI
77412 99480 NCCI
77412 99485 NCCI
77412 G0459 NCCI
77412 M0064 NCCI
77413 11920 NCCI
77413 11921 NCCI
77413 16000 NCCI
77413 16020 NCCI
77413 16025 NCCI
77413 16030 NCCI
77413 36000 NCCI
77413 36410 NCCI
77413 36425 NCCI
77413 51701 NCCI
77413 51702 NCCI
77413 51703 NCCI
77413 76376 NCCI
77413 76377 NCCI
77413 77401 NCCI
77413 77402 NCCI
77413 77403 NCCI
77413 77404 NCCI
77413 77406 NCCI
77413 77407 NCCI
77413 77408 NCCI
77413 77409 NCCI
77413 77411 NCCI
77413 77412 NCCI
77413 77422 NCCI
77413 77423 NCCI
77413 90832 NCCI
77413 90833 NCCI
77413 90834 NCCI
77413 90836 NCCI
77413 90837 NCCI
77413 90838 NCCI
77413 90839 NCCI
77413 90846 NCCI
77413 90847 NCCI
77413 96360 NCCI
77413 96361 NCCI
77413 96365 NCCI
77413 96366 NCCI
77413 96367 NCCI
77413 96368 NCCI
77413 97802 NCCI
Comprehensive ComponentCode Code Source
77413 97803 NCCI
77413 97804 NCCI
77413 99143 NCCI
77413 99144 NCCI
77413 99145 NCCI
77413 99201 NCCI
77413 99202 NCCI
77413 99203 NCCI
77413 99204 NCCI
77413 99205 NCCI
77413 99211 NCCI
77413 99212 NCCI
77413 99213 NCCI
77413 99214 NCCI
77413 99215 NCCI
77413 99217 NCCI
77413 99218 NCCI
77413 99219 NCCI
77413 99220 NCCI
77413 99221 NCCI
77413 99222 NCCI
77413 99223 NCCI
77413 99224 NCCI
77413 99225 NCCI
77413 99226 NCCI
77413 99231 NCCI
77413 99232 NCCI
77413 99233 NCCI
77413 99234 NCCI
77413 99235 NCCI
77413 99236 NCCI
77413 99238 NCCI
77413 99239 NCCI
77413 99281 NCCI
77413 99282 NCCI
77413 99283 NCCI
77413 99284 NCCI
77413 99285 NCCI
77413 99291 NCCI
77413 99292 NCCI
77413 99304 NCCI
77413 99305 NCCI
77413 99306 NCCI
77413 99307 NCCI
77413 99308 NCCI
77413 99309 NCCI
77413 99310 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 112 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77413 99315 NCCI
77413 99316 NCCI
77413 99318 NCCI
77413 99324 NCCI
77413 99325 NCCI
77413 99326 NCCI
77413 99327 NCCI
77413 99328 NCCI
77413 99334 NCCI
77413 99335 NCCI
77413 99336 NCCI
77413 99337 NCCI
77413 99341 NCCI
77413 99342 NCCI
77413 99343 NCCI
77413 99344 NCCI
77413 99345 NCCI
77413 99347 NCCI
77413 99348 NCCI
77413 99349 NCCI
77413 99350 NCCI
77413 99354 NCCI
77413 99355 NCCI
77413 99356 NCCI
77413 99357 NCCI
77413 99360 NCCI
77413 99455 NCCI
77413 99456 NCCI
77413 99460 NCCI
77413 99461 NCCI
77413 99462 NCCI
77413 99463 NCCI
77413 99464 NCCI
77413 99465 NCCI
77413 99466 NCCI
77413 99467 NCCI
77413 99468 NCCI
77413 99469 NCCI
77413 99471 NCCI
77413 99472 NCCI
77413 99475 NCCI
77413 99476 NCCI
77413 99477 NCCI
77413 99478 NCCI
77413 99479 NCCI
77413 99480 NCCI
77413 99485 NCCI
Comprehensive ComponentCode Code Source
77413 G0459 NCCI
77413 M0064 NCCI
77414 11920 NCCI
77414 11921 NCCI
77414 16000 NCCI
77414 16020 NCCI
77414 16025 NCCI
77414 16030 NCCI
77414 36000 NCCI
77414 36410 NCCI
77414 36425 NCCI
77414 51701 NCCI
77414 51702 NCCI
77414 51703 NCCI
77414 76376 NCCI
77414 76377 NCCI
77414 77401 NCCI
77414 77402 NCCI
77414 77403 NCCI
77414 77404 NCCI
77414 77406 NCCI
77414 77407 NCCI
77414 77408 NCCI
77414 77409 NCCI
77414 77411 NCCI
77414 77412 NCCI
77414 77413 NCCI
77414 77422 NCCI
77414 77423 NCCI
77414 90832 NCCI
77414 90833 NCCI
77414 90834 NCCI
77414 90836 NCCI
77414 90837 NCCI
77414 90838 NCCI
77414 90839 NCCI
77414 90846 NCCI
77414 90847 NCCI
77414 96360 NCCI
77414 96361 NCCI
77414 96365 NCCI
77414 96366 NCCI
77414 96367 NCCI
77414 96368 NCCI
77414 97802 NCCI
77414 97803 NCCI
77414 97804 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 113 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77414 99143 NCCI
77414 99144 NCCI
77414 99145 NCCI
77414 99201 NCCI
77414 99202 NCCI
77414 99203 NCCI
77414 99204 NCCI
77414 99205 NCCI
77414 99211 NCCI
77414 99212 NCCI
77414 99213 NCCI
77414 99214 NCCI
77414 99215 NCCI
77414 99217 NCCI
77414 99218 NCCI
77414 99219 NCCI
77414 99220 NCCI
77414 99221 NCCI
77414 99222 NCCI
77414 99223 NCCI
77414 99224 NCCI
77414 99225 NCCI
77414 99226 NCCI
77414 99231 NCCI
77414 99232 NCCI
77414 99233 NCCI
77414 99234 NCCI
77414 99235 NCCI
77414 99236 NCCI
77414 99238 NCCI
77414 99239 NCCI
77414 99281 NCCI
77414 99282 NCCI
77414 99283 NCCI
77414 99284 NCCI
77414 99285 NCCI
77414 99291 NCCI
77414 99292 NCCI
77414 99304 NCCI
77414 99305 NCCI
77414 99306 NCCI
77414 99307 NCCI
77414 99308 NCCI
77414 99309 NCCI
77414 99310 NCCI
77414 99315 NCCI
77414 99316 NCCI
Comprehensive ComponentCode Code Source
77414 99318 NCCI
77414 99324 NCCI
77414 99325 NCCI
77414 99326 NCCI
77414 99327 NCCI
77414 99328 NCCI
77414 99334 NCCI
77414 99335 NCCI
77414 99336 NCCI
77414 99337 NCCI
77414 99341 NCCI
77414 99342 NCCI
77414 99343 NCCI
77414 99344 NCCI
77414 99345 NCCI
77414 99347 NCCI
77414 99348 NCCI
77414 99349 NCCI
77414 99350 NCCI
77414 99354 NCCI
77414 99355 NCCI
77414 99356 NCCI
77414 99357 NCCI
77414 99360 NCCI
77414 99455 NCCI
77414 99456 NCCI
77414 99460 NCCI
77414 99461 NCCI
77414 99462 NCCI
77414 99463 NCCI
77414 99464 NCCI
77414 99465 NCCI
77414 99466 NCCI
77414 99467 NCCI
77414 99468 NCCI
77414 99469 NCCI
77414 99471 NCCI
77414 99472 NCCI
77414 99475 NCCI
77414 99476 NCCI
77414 99477 NCCI
77414 99478 NCCI
77414 99479 NCCI
77414 99480 NCCI
77414 99485 NCCI
77414 G0459 NCCI
77414 M0064 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 114 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77416 11920 NCCI
77416 11921 NCCI
77416 16000 NCCI
77416 16020 NCCI
77416 16025 NCCI
77416 16030 NCCI
77416 36000 NCCI
77416 36410 NCCI
77416 36425 NCCI
77416 51701 NCCI
77416 51702 NCCI
77416 51703 NCCI
77416 76376 NCCI
77416 76377 NCCI
77416 77401 NCCI
77416 77402 NCCI
77416 77403 NCCI
77416 77404 NCCI
77416 77406 NCCI
77416 77407 NCCI
77416 77408 NCCI
77416 77409 NCCI
77416 77411 NCCI
77416 77412 NCCI
77416 77413 NCCI
77416 77414 NCCI
77416 77422 NCCI
77416 77423 NCCI
77416 90832 NCCI
77416 90833 NCCI
77416 90834 NCCI
77416 90836 NCCI
77416 90837 NCCI
77416 90838 NCCI
77416 90839 NCCI
77416 90846 NCCI
77416 90847 NCCI
77416 96360 NCCI
77416 96361 NCCI
77416 96365 NCCI
77416 96366 NCCI
77416 96367 NCCI
77416 96368 NCCI
77416 97802 NCCI
77416 97803 NCCI
77416 97804 NCCI
77416 99143 NCCI
Comprehensive ComponentCode Code Source
77416 99144 NCCI
77416 99145 NCCI
77416 99201 NCCI
77416 99202 NCCI
77416 99203 NCCI
77416 99204 NCCI
77416 99205 NCCI
77416 99211 NCCI
77416 99212 NCCI
77416 99213 NCCI
77416 99214 NCCI
77416 99215 NCCI
77416 99217 NCCI
77416 99218 NCCI
77416 99219 NCCI
77416 99220 NCCI
77416 99221 NCCI
77416 99222 NCCI
77416 99223 NCCI
77416 99224 NCCI
77416 99225 NCCI
77416 99226 NCCI
77416 99231 NCCI
77416 99232 NCCI
77416 99233 NCCI
77416 99234 NCCI
77416 99235 NCCI
77416 99236 NCCI
77416 99238 NCCI
77416 99239 NCCI
77416 99281 NCCI
77416 99282 NCCI
77416 99283 NCCI
77416 99284 NCCI
77416 99285 NCCI
77416 99291 NCCI
77416 99292 NCCI
77416 99304 NCCI
77416 99305 NCCI
77416 99306 NCCI
77416 99307 NCCI
77416 99308 NCCI
77416 99309 NCCI
77416 99310 NCCI
77416 99315 NCCI
77416 99316 NCCI
77416 99318 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 115 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77416 99324 NCCI
77416 99325 NCCI
77416 99326 NCCI
77416 99327 NCCI
77416 99328 NCCI
77416 99334 NCCI
77416 99335 NCCI
77416 99336 NCCI
77416 99337 NCCI
77416 99341 NCCI
77416 99342 NCCI
77416 99343 NCCI
77416 99344 NCCI
77416 99345 NCCI
77416 99347 NCCI
77416 99348 NCCI
77416 99349 NCCI
77416 99350 NCCI
77416 99354 NCCI
77416 99355 NCCI
77416 99356 NCCI
77416 99357 NCCI
77416 99360 NCCI
77416 99455 NCCI
77416 99456 NCCI
77416 99460 NCCI
77416 99461 NCCI
77416 99462 NCCI
77416 99463 NCCI
77416 99464 NCCI
77416 99465 NCCI
77416 99466 NCCI
77416 99467 NCCI
77416 99468 NCCI
77416 99469 NCCI
77416 99471 NCCI
77416 99472 NCCI
77416 99475 NCCI
77416 99476 NCCI
77416 99477 NCCI
77416 99478 NCCI
77416 99479 NCCI
77416 99480 NCCI
77416 99485 NCCI
77416 G0459 NCCI
77416 M0064 NCCI
77417 11920 NCCI
Comprehensive ComponentCode Code Source
77417 11921 NCCI
77417 16000 NCCI
77417 16020 NCCI
77417 16025 NCCI
77417 16030 NCCI
77417 36000 NCCI
77417 36410 NCCI
77417 36425 NCCI
77417 51701 NCCI
77417 51702 NCCI
77417 51703 NCCI
77417 77417 CPT
77417 90832 NCCI
77417 90833 NCCI
77417 90834 NCCI
77417 90836 NCCI
77417 90837 NCCI
77417 90838 NCCI
77417 90839 NCCI
77417 90846 NCCI
77417 90847 NCCI
77417 96360 NCCI
77417 96361 NCCI
77417 96365 NCCI
77417 96366 NCCI
77417 96367 NCCI
77417 96368 NCCI
77417 97802 NCCI
77417 97803 NCCI
77417 97804 NCCI
77417 99143 NCCI
77417 99144 NCCI
77417 99145 NCCI
77417 99201 NCCI
77417 99202 NCCI
77417 99203 NCCI
77417 99204 NCCI
77417 99205 NCCI
77417 99211 NCCI
77417 99212 NCCI
77417 99213 NCCI
77417 99214 NCCI
77417 99215 NCCI
77417 99217 NCCI
77417 99218 NCCI
77417 99219 NCCI
77417 99220 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 116 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77417 99221 NCCI
77417 99222 NCCI
77417 99223 NCCI
77417 99224 NCCI
77417 99225 NCCI
77417 99226 NCCI
77417 99231 NCCI
77417 99232 NCCI
77417 99233 NCCI
77417 99234 NCCI
77417 99235 NCCI
77417 99236 NCCI
77417 99238 NCCI
77417 99239 NCCI
77417 99281 NCCI
77417 99282 NCCI
77417 99283 NCCI
77417 99284 NCCI
77417 99285 NCCI
77417 99291 NCCI
77417 99292 NCCI
77417 99304 NCCI
77417 99305 NCCI
77417 99306 NCCI
77417 99307 NCCI
77417 99308 NCCI
77417 99309 NCCI
77417 99310 NCCI
77417 99315 NCCI
77417 99316 NCCI
77417 99318 NCCI
77417 99324 NCCI
77417 99325 NCCI
77417 99326 NCCI
77417 99327 NCCI
77417 99328 NCCI
77417 99334 NCCI
77417 99335 NCCI
77417 99336 NCCI
77417 99337 NCCI
77417 99341 NCCI
77417 99342 NCCI
77417 99343 NCCI
77417 99344 NCCI
77417 99345 NCCI
77417 99347 NCCI
77417 99348 NCCI
Comprehensive ComponentCode Code Source
77417 99349 NCCI
77417 99350 NCCI
77417 99354 NCCI
77417 99355 NCCI
77417 99356 NCCI
77417 99357 NCCI
77417 99360 NCCI
77417 99455 NCCI
77417 99456 NCCI
77417 99460 NCCI
77417 99461 NCCI
77417 99462 NCCI
77417 99463 NCCI
77417 99464 NCCI
77417 99465 NCCI
77417 99466 NCCI
77417 99467 NCCI
77417 99468 NCCI
77417 99469 NCCI
77417 99471 NCCI
77417 99472 NCCI
77417 99475 NCCI
77417 99476 NCCI
77417 99477 NCCI
77417 99478 NCCI
77417 99479 NCCI
77417 99480 NCCI
77417 99485 NCCI
77417 G0459 NCCI
77417 M0064 NCCI
77418 0073T NCCI
77418 11920 BCBST
77418 11921 BCBST
77418 16000 BCBST
77418 16020 BCBST
77418 16025 BCBST
77418 16030 BCBST
77418 36000 NCCI
77418 36410 NCCI
77418 36425 BCBST
77418 51701 NCCI
77418 51702 NCCI
77418 51703 NCCI
77418 76506 NCCI
77418 76511 NCCI
77418 76512 NCCI
77418 76513 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 117 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77418 76516 NCCI
77418 76519 NCCI
77418 76529 NCCI
77418 76536 NCCI
77418 76604 NCCI
77418 76645 NCCI
77418 76700 NCCI
77418 76705 NCCI
77418 76770 NCCI
77418 76775 NCCI
77418 76800 NCCI
77418 76805 NCCI
77418 76810 NCCI
77418 76815 NCCI
77418 76816 NCCI
77418 76818 NCCI
77418 76819 NCCI
77418 76825 NCCI
77418 76826 NCCI
77418 76827 NCCI
77418 76828 NCCI
77418 76830 NCCI
77418 76831 NCCI
77418 76856 NCCI
77418 76857 NCCI
77418 76870 NCCI
77418 76872 NCCI
77418 76873 NCCI
77418 76881 NCCI
77418 76882 NCCI
77418 76885 NCCI
77418 76886 NCCI
77418 76930 NCCI
77418 76932 NCCI
77418 76936 NCCI
77418 76941 NCCI
77418 76942 NCCI
77418 76945 NCCI
77418 76946 NCCI
77418 76948 NCCI
77418 76965 NCCI
77418 76970 NCCI
77418 76975 NCCI
77418 76977 NCCI
77418 76998 NCCI
77418 77261 NCCI
77418 77262 NCCI
Comprehensive ComponentCode Code Source
77418 77263 NCCI
77418 77305 NCCI
77418 77310 NCCI
77418 77315 NCCI
77418 77321 NCCI
77418 77326 NCCI
77418 77327 NCCI
77418 77328 NCCI
77418 77331 NCCI
77418 77332 NCCI
77418 77333 NCCI
77418 77334 NCCI
77418 77338 NCCI
77418 77371 NCCI
77418 77372 NCCI
77418 77373 NCCI
77418 77401 NCCI
77418 77402 NCCI
77418 77403 NCCI
77418 77404 NCCI
77418 77406 NCCI
77418 77407 NCCI
77418 77408 NCCI
77418 77409 NCCI
77418 77411 NCCI
77418 77412 NCCI
77418 77413 NCCI
77418 77414 NCCI
77418 77416 NCCI
77418 77422 NCCI
77418 77423 NCCI
77418 77432 NCCI
77418 77435 NCCI
77418 77469 NCCI
77418 77470 NCCI
77418 77520 NCCI
77418 77522 NCCI
77418 77523 NCCI
77418 77525 NCCI
77418 90832 NCCI
77418 90833 NCCI
77418 90834 NCCI
77418 90836 NCCI
77418 90837 NCCI
77418 90838 NCCI
77418 90839 NCCI
77418 90846 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 118 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77418 90847 BCBST
77418 96360 NCCI
77418 96361 NCCI
77418 96365 NCCI
77418 96366 NCCI
77418 96367 NCCI
77418 96368 NCCI
77418 97802 NCCI
77418 97803 NCCI
77418 97804 NCCI
77418 99143 NCCI
77418 99144 NCCI
77418 99145 NCCI
77418 99201 BCBST
77418 99202 BCBST
77418 99203 BCBST
77418 99204 BCBST
77418 99205 BCBST
77418 99211 BCBST
77418 99212 BCBST
77418 99213 BCBST
77418 99214 BCBST
77418 99215 BCBST
77418 99217 BCBST
77418 99218 BCBST
77418 99219 BCBST
77418 99220 BCBST
77418 99221 BCBST
77418 99222 BCBST
77418 99223 BCBST
77418 99224 NCCI
77418 99225 NCCI
77418 99226 NCCI
77418 99231 BCBST
77418 99232 BCBST
77418 99233 BCBST
77418 99234 BCBST
77418 99235 BCBST
77418 99236 BCBST
77418 99238 BCBST
77418 99239 NCCI
77418 99281 BCBST
77418 99282 BCBST
77418 99283 BCBST
77418 99284 BCBST
77418 99285 BCBST
77418 99291 NCCI
Comprehensive ComponentCode Code Source
77418 99292 NCCI
77418 99304 NCCI
77418 99305 NCCI
77418 99306 NCCI
77418 99307 NCCI
77418 99308 NCCI
77418 99309 NCCI
77418 99310 NCCI
77418 99315 NCCI
77418 99316 NCCI
77418 99318 NCCI
77418 99324 NCCI
77418 99325 NCCI
77418 99326 NCCI
77418 99327 NCCI
77418 99328 NCCI
77418 99334 NCCI
77418 99335 NCCI
77418 99336 NCCI
77418 99337 NCCI
77418 99341 NCCI
77418 99342 NCCI
77418 99343 NCCI
77418 99344 NCCI
77418 99345 NCCI
77418 99347 NCCI
77418 99348 NCCI
77418 99349 NCCI
77418 99350 NCCI
77418 99354 BCBST
77418 99355 NCCI
77418 99356 BCBST
77418 99357 NCCI
77418 99360 NCCI
77418 99455 NCCI
77418 99456 NCCI
77418 99460 NCCI
77418 99461 NCCI
77418 99462 NCCI
77418 99463 NCCI
77418 99464 NCCI
77418 99465 NCCI
77418 99466 NCCI
77418 99467 NCCI
77418 99468 NCCI
77418 99469 NCCI
77418 99471 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 119 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77418 99472 NCCI
77418 99475 NCCI
77418 99476 NCCI
77418 99477 NCCI
77418 99478 NCCI
77418 99479 NCCI
77418 99480 NCCI
77418 99485 NCCI
77418 G0339 NCCI
77418 G0340 NCCI
77418 G0459 NCCI
77418 M0064 NCCI
77421 0197T NCCI
77421 11920 NCCI
77421 11921 NCCI
77421 16000 NCCI
77421 16020 NCCI
77421 16025 NCCI
77421 16030 NCCI
77421 36000 NCCI
77421 36410 NCCI
77421 36425 NCCI
77421 51701 NCCI
77421 51702 NCCI
77421 51703 NCCI
77421 76950 NCCI
77421 90832 NCCI
77421 90833 NCCI
77421 90834 NCCI
77421 90836 NCCI
77421 90837 NCCI
77421 90838 NCCI
77421 90839 NCCI
77421 90846 NCCI
77421 90847 NCCI
77421 96360 NCCI
77421 96361 NCCI
77421 96365 NCCI
77421 96366 NCCI
77421 96367 NCCI
77421 96368 NCCI
77421 97802 NCCI
77421 97803 NCCI
77421 97804 NCCI
77421 99143 NCCI
77421 99144 NCCI
77421 99145 NCCI
Comprehensive ComponentCode Code Source
77421 99201 NCCI
77421 99202 NCCI
77421 99203 NCCI
77421 99204 NCCI
77421 99205 NCCI
77421 99211 NCCI
77421 99212 NCCI
77421 99213 NCCI
77421 99214 NCCI
77421 99215 NCCI
77421 99217 NCCI
77421 99218 NCCI
77421 99219 NCCI
77421 99220 NCCI
77421 99221 NCCI
77421 99222 NCCI
77421 99223 NCCI
77421 99224 NCCI
77421 99225 NCCI
77421 99226 NCCI
77421 99231 NCCI
77421 99232 NCCI
77421 99233 NCCI
77421 99234 NCCI
77421 99235 NCCI
77421 99236 NCCI
77421 99238 NCCI
77421 99239 NCCI
77421 99281 NCCI
77421 99282 NCCI
77421 99283 NCCI
77421 99284 NCCI
77421 99285 NCCI
77421 99291 NCCI
77421 99292 NCCI
77421 99304 NCCI
77421 99305 NCCI
77421 99306 NCCI
77421 99307 NCCI
77421 99308 NCCI
77421 99309 NCCI
77421 99310 NCCI
77421 99315 NCCI
77421 99316 NCCI
77421 99318 NCCI
77421 99324 NCCI
77421 99325 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 120 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77421 99326 NCCI
77421 99327 NCCI
77421 99328 NCCI
77421 99334 NCCI
77421 99335 NCCI
77421 99336 NCCI
77421 99337 NCCI
77421 99341 NCCI
77421 99342 NCCI
77421 99343 NCCI
77421 99344 NCCI
77421 99345 NCCI
77421 99347 NCCI
77421 99348 NCCI
77421 99349 NCCI
77421 99350 NCCI
77421 99354 NCCI
77421 99355 NCCI
77421 99356 NCCI
77421 99357 NCCI
77421 99360 NCCI
77421 99455 NCCI
77421 99456 NCCI
77421 99460 NCCI
77421 99461 NCCI
77421 99462 NCCI
77421 99463 NCCI
77421 99464 NCCI
77421 99465 NCCI
77421 99466 NCCI
77421 99467 NCCI
77421 99468 NCCI
77421 99469 NCCI
77421 99471 NCCI
77421 99472 NCCI
77421 99475 NCCI
77421 99476 NCCI
77421 99477 NCCI
77421 99478 NCCI
77421 99479 NCCI
77421 99480 NCCI
77421 99485 NCCI
77421 G0459 NCCI
77421 M0064 NCCI
77422 11920 NCCI
77422 11921 NCCI
77422 16000 NCCI
Comprehensive ComponentCode Code Source
77422 16020 NCCI
77422 16025 NCCI
77422 16030 NCCI
77422 36000 NCCI
77422 36410 NCCI
77422 36425 NCCI
77422 51701 NCCI
77422 51702 NCCI
77422 51703 NCCI
77422 77520 NCCI
77422 90832 NCCI
77422 90833 NCCI
77422 90834 NCCI
77422 90836 NCCI
77422 90837 NCCI
77422 90838 NCCI
77422 90839 NCCI
77422 90846 NCCI
77422 90847 NCCI
77422 96360 NCCI
77422 96361 NCCI
77422 96365 NCCI
77422 96366 NCCI
77422 96367 NCCI
77422 96368 NCCI
77422 97802 NCCI
77422 97803 NCCI
77422 97804 NCCI
77422 99143 NCCI
77422 99144 NCCI
77422 99145 NCCI
77422 99201 NCCI
77422 99202 NCCI
77422 99203 NCCI
77422 99204 NCCI
77422 99205 NCCI
77422 99211 NCCI
77422 99212 NCCI
77422 99213 NCCI
77422 99214 NCCI
77422 99215 NCCI
77422 99217 NCCI
77422 99218 NCCI
77422 99219 NCCI
77422 99220 NCCI
77422 99221 NCCI
77422 99222 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 121 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77422 99223 NCCI
77422 99224 NCCI
77422 99225 NCCI
77422 99226 NCCI
77422 99231 NCCI
77422 99232 NCCI
77422 99233 NCCI
77422 99234 NCCI
77422 99235 NCCI
77422 99236 NCCI
77422 99238 NCCI
77422 99239 NCCI
77422 99281 NCCI
77422 99282 NCCI
77422 99283 NCCI
77422 99284 NCCI
77422 99285 NCCI
77422 99291 NCCI
77422 99292 NCCI
77422 99304 NCCI
77422 99305 NCCI
77422 99306 NCCI
77422 99307 NCCI
77422 99308 NCCI
77422 99309 NCCI
77422 99310 NCCI
77422 99315 NCCI
77422 99316 NCCI
77422 99318 NCCI
77422 99324 NCCI
77422 99325 NCCI
77422 99326 NCCI
77422 99327 NCCI
77422 99328 NCCI
77422 99334 NCCI
77422 99335 NCCI
77422 99336 NCCI
77422 99337 NCCI
77422 99341 NCCI
77422 99342 NCCI
77422 99343 NCCI
77422 99344 NCCI
77422 99345 NCCI
77422 99347 NCCI
77422 99348 NCCI
77422 99349 NCCI
77422 99350 NCCI
Comprehensive ComponentCode Code Source
77422 99354 NCCI
77422 99355 NCCI
77422 99356 NCCI
77422 99357 NCCI
77422 99360 NCCI
77422 99455 NCCI
77422 99456 NCCI
77422 99460 NCCI
77422 99461 NCCI
77422 99462 NCCI
77422 99463 NCCI
77422 99464 NCCI
77422 99465 NCCI
77422 99466 NCCI
77422 99467 NCCI
77422 99468 NCCI
77422 99469 NCCI
77422 99471 NCCI
77422 99472 NCCI
77422 99475 NCCI
77422 99476 NCCI
77422 99477 NCCI
77422 99478 NCCI
77422 99479 NCCI
77422 99480 NCCI
77422 99485 NCCI
77422 G0459 NCCI
77422 M0064 NCCI
77423 11920 NCCI
77423 11921 NCCI
77423 16000 NCCI
77423 16020 NCCI
77423 16025 NCCI
77423 16030 NCCI
77423 36000 NCCI
77423 36410 NCCI
77423 36425 NCCI
77423 51701 NCCI
77423 51702 NCCI
77423 51703 NCCI
77423 77401 NCCI
77423 77402 NCCI
77423 77403 NCCI
77423 77404 NCCI
77423 77406 NCCI
77423 77407 NCCI
77423 77408 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 122 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77423 77409 NCCI
77423 77411 NCCI
77423 77422 NCCI
77423 77520 NCCI
77423 90832 NCCI
77423 90833 NCCI
77423 90834 NCCI
77423 90836 NCCI
77423 90837 NCCI
77423 90838 NCCI
77423 90839 NCCI
77423 90846 NCCI
77423 90847 NCCI
77423 96360 NCCI
77423 96361 NCCI
77423 96365 NCCI
77423 96366 NCCI
77423 96367 NCCI
77423 96368 NCCI
77423 97802 NCCI
77423 97803 NCCI
77423 97804 NCCI
77423 99143 NCCI
77423 99144 NCCI
77423 99145 NCCI
77423 99201 NCCI
77423 99202 NCCI
77423 99203 NCCI
77423 99204 NCCI
77423 99205 NCCI
77423 99211 NCCI
77423 99212 NCCI
77423 99213 NCCI
77423 99214 NCCI
77423 99215 NCCI
77423 99217 NCCI
77423 99218 NCCI
77423 99219 NCCI
77423 99220 NCCI
77423 99221 NCCI
77423 99222 NCCI
77423 99223 NCCI
77423 99224 NCCI
77423 99225 NCCI
77423 99226 NCCI
77423 99231 NCCI
77423 99232 NCCI
Comprehensive ComponentCode Code Source
77423 99233 NCCI
77423 99234 NCCI
77423 99235 NCCI
77423 99236 NCCI
77423 99238 NCCI
77423 99239 NCCI
77423 99281 NCCI
77423 99282 NCCI
77423 99283 NCCI
77423 99284 NCCI
77423 99285 NCCI
77423 99291 NCCI
77423 99292 NCCI
77423 99304 NCCI
77423 99305 NCCI
77423 99306 NCCI
77423 99307 NCCI
77423 99308 NCCI
77423 99309 NCCI
77423 99310 NCCI
77423 99315 NCCI
77423 99316 NCCI
77423 99318 NCCI
77423 99324 NCCI
77423 99325 NCCI
77423 99326 NCCI
77423 99327 NCCI
77423 99328 NCCI
77423 99334 NCCI
77423 99335 NCCI
77423 99336 NCCI
77423 99337 NCCI
77423 99341 NCCI
77423 99342 NCCI
77423 99343 NCCI
77423 99344 NCCI
77423 99345 NCCI
77423 99347 NCCI
77423 99348 NCCI
77423 99349 NCCI
77423 99350 NCCI
77423 99354 NCCI
77423 99355 NCCI
77423 99356 NCCI
77423 99357 NCCI
77423 99360 NCCI
77423 99455 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 123 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77423 99456 NCCI
77423 99460 NCCI
77423 99461 NCCI
77423 99462 NCCI
77423 99463 NCCI
77423 99464 NCCI
77423 99465 NCCI
77423 99466 NCCI
77423 99467 NCCI
77423 99468 NCCI
77423 99469 NCCI
77423 99471 NCCI
77423 99472 NCCI
77423 99475 NCCI
77423 99476 NCCI
77423 99477 NCCI
77423 99478 NCCI
77423 99479 NCCI
77423 99480 NCCI
77423 99485 NCCI
77423 G0459 NCCI
77423 M0064 NCCI
77424 11920 NCCI
77424 11921 NCCI
77424 16000 NCCI
77424 16020 NCCI
77424 16025 NCCI
77424 16030 NCCI
77424 36000 NCCI
77424 36410 NCCI
77424 36425 NCCI
77424 51701 NCCI
77424 51702 NCCI
77424 51703 NCCI
77424 90832 NCCI
77424 90833 NCCI
77424 90834 NCCI
77424 90836 NCCI
77424 90837 NCCI
77424 90838 NCCI
77424 90839 NCCI
77424 90846 NCCI
77424 90847 NCCI
77424 96360 NCCI
77424 96361 NCCI
77424 96365 NCCI
77424 96366 NCCI
Comprehensive ComponentCode Code Source
77424 96367 NCCI
77424 96368 NCCI
77424 97802 NCCI
77424 97803 NCCI
77424 97804 NCCI
77424 99143 NCCI
77424 99144 NCCI
77424 99145 NCCI
77424 99201 NCCI
77424 99202 NCCI
77424 99203 NCCI
77424 99204 NCCI
77424 99205 NCCI
77424 99211 NCCI
77424 99212 NCCI
77424 99213 NCCI
77424 99214 NCCI
77424 99215 NCCI
77424 99217 NCCI
77424 99218 NCCI
77424 99219 NCCI
77424 99220 NCCI
77424 99221 NCCI
77424 99222 NCCI
77424 99223 NCCI
77424 99224 NCCI
77424 99225 NCCI
77424 99226 NCCI
77424 99231 NCCI
77424 99232 NCCI
77424 99233 NCCI
77424 99234 NCCI
77424 99235 NCCI
77424 99236 NCCI
77424 99238 NCCI
77424 99239 NCCI
77424 99281 NCCI
77424 99282 NCCI
77424 99283 NCCI
77424 99284 NCCI
77424 99285 NCCI
77424 99291 NCCI
77424 99292 NCCI
77424 99304 NCCI
77424 99305 NCCI
77424 99306 NCCI
77424 99307 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 124 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77424 99308 NCCI
77424 99309 NCCI
77424 99310 NCCI
77424 99315 NCCI
77424 99316 NCCI
77424 99318 NCCI
77424 99324 NCCI
77424 99325 NCCI
77424 99326 NCCI
77424 99327 NCCI
77424 99328 NCCI
77424 99334 NCCI
77424 99335 NCCI
77424 99336 NCCI
77424 99337 NCCI
77424 99341 NCCI
77424 99342 NCCI
77424 99343 NCCI
77424 99344 NCCI
77424 99345 NCCI
77424 99347 NCCI
77424 99348 NCCI
77424 99349 NCCI
77424 99350 NCCI
77424 99354 NCCI
77424 99355 NCCI
77424 99356 NCCI
77424 99357 NCCI
77424 99360 NCCI
77424 99455 NCCI
77424 99456 NCCI
77424 99460 NCCI
77424 99461 NCCI
77424 99462 NCCI
77424 99463 NCCI
77424 99464 NCCI
77424 99465 NCCI
77424 99466 NCCI
77424 99467 NCCI
77424 99468 NCCI
77424 99469 NCCI
77424 99471 NCCI
77424 99472 NCCI
77424 99475 NCCI
77424 99476 NCCI
77424 99477 NCCI
77424 99478 NCCI
Comprehensive ComponentCode Code Source
77424 99479 NCCI
77424 99480 NCCI
77424 99485 NCCI
77424 G0459 NCCI
77424 M0064 NCCI
77425 11920 NCCI
77425 11921 NCCI
77425 16000 NCCI
77425 16020 NCCI
77425 16025 NCCI
77425 16030 NCCI
77425 36000 NCCI
77425 36410 NCCI
77425 36425 NCCI
77425 51701 NCCI
77425 51702 NCCI
77425 51703 NCCI
77425 90832 NCCI
77425 90833 NCCI
77425 90834 NCCI
77425 90836 NCCI
77425 90837 NCCI
77425 90838 NCCI
77425 90839 NCCI
77425 90846 NCCI
77425 96360 NCCI
77425 96361 NCCI
77425 96365 NCCI
77425 96366 NCCI
77425 96367 NCCI
77425 96368 NCCI
77425 97802 NCCI
77425 97803 NCCI
77425 97804 NCCI
77425 99143 NCCI
77425 99144 NCCI
77425 99145 NCCI
77425 99201 NCCI
77425 99202 NCCI
77425 99202 NCCI
77425 99211 NCCI
77425 99213 NCCI
77425 99213 NCCI
77425 99214 NCCI
77425 99214 NCCI
77425 99215 NCCI
77425 99215 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 125 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77425 99217 NCCI
77425 99217 NCCI
77425 99218 NCCI
77425 99219 NCCI
77425 99220 NCCI
77425 99220 NCCI
77425 99221 NCCI
77425 99221 NCCI
77425 99222 NCCI
77425 99223 NCCI
77425 99224 NCCI
77425 99225 NCCI
77425 99226 NCCI
77425 99231 NCCI
77425 99232 NCCI
77425 99233 NCCI
77425 99234 NCCI
77425 99235 NCCI
77425 99236 NCCI
77425 99239 NCCI
77425 99281 NCCI
77425 99282 NCCI
77425 99283 NCCI
77425 99284 NCCI
77425 99285 NCCI
77425 99291 NCCI
77425 99292 NCCI
77425 99304 NCCI
77425 99305 NCCI
77425 99306 NCCI
77425 99307 NCCI
77425 99308 NCCI
77425 99309 NCCI
77425 99310 NCCI
77425 99315 NCCI
77425 99316 NCCI
77425 99318 NCCI
77425 99324 NCCI
77425 99325 NCCI
77425 99326 NCCI
77425 99327 NCCI
77425 99328 NCCI
77425 99334 NCCI
77425 99335 NCCI
77425 99336 NCCI
77425 99337 NCCI
77425 99341 NCCI
Comprehensive ComponentCode Code Source
77425 99342 NCCI
77425 99343 NCCI
77425 99344 NCCI
77425 99345 NCCI
77425 99347 NCCI
77425 99348 NCCI
77425 99349 NCCI
77425 99350 NCCI
77425 99355 NCCI
77425 99356 NCCI
77425 99357 NCCI
77425 99360 NCCI
77425 99360 NCCI
77425 99455 NCCI
77425 99456 NCCI
77425 99460 NCCI
77425 99461 NCCI
77425 99462 NCCI
77425 99463 NCCI
77425 99464 NCCI
77425 99465 NCCI
77425 99466 NCCI
77425 99467 NCCI
77425 99468 NCCI
77425 99469 NCCI
77425 99471 NCCI
77425 99472 NCCI
77425 99475 NCCI
77425 99476 NCCI
77425 99477 NCCI
77425 99478 NCCI
77425 99479 NCCI
77425 99480 NCCI
77425 99485 NCCI
77425 G0459 NCCI
77425 M0064 NCCI
77427 11920 NCCI
77427 11921 NCCI
77427 16000 NCCI
77427 16020 NCCI
77427 16025 NCCI
77427 16030 NCCI
77427 36000 NCCI
77427 36410 NCCI
77427 36425 NCCI
77427 51701 NCCI
77427 51702 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 126 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77427 51703 NCCI
77427 77432 NCCI
77427 90832 NCCI
77427 90833 NCCI
77427 90834 NCCI
77427 90836 NCCI
77427 90837 NCCI
77427 90838 NCCI
77427 90839 NCCI
77427 90846 NCCI
77427 90847 NCCI
77427 96150 NCCI
77427 96151 NCCI
77427 96152 NCCI
77427 96153 NCCI
77427 96154 NCCI
77427 96360 NCCI
77427 96361 NCCI
77427 96365 NCCI
77427 96366 NCCI
77427 96367 NCCI
77427 96368 NCCI
77427 97802 NCCI
77427 97803 NCCI
77427 97804 NCCI
77427 99143 NCCI
77427 99144 NCCI
77427 99145 NCCI
77427 99183 NCCI
77427 99201 NCCI
77427 99202 NCCI
77427 99203 NCCI
77427 99204 NCCI
77427 99205 NCCI
77427 99211 NCCI
77427 99212 NCCI
77427 99213 NCCI
77427 99214 NCCI
77427 99215 NCCI
77427 99217 NCCI
77427 99218 NCCI
77427 99219 NCCI
77427 99220 NCCI
77427 99221 NCCI
77427 99222 NCCI
77427 99223 NCCI
77427 99224 NCCI
Comprehensive ComponentCode Code Source
77427 99225 NCCI
77427 99226 NCCI
77427 99231 NCCI
77427 99232 NCCI
77427 99233 NCCI
77427 99234 NCCI
77427 99235 NCCI
77427 99235 NCCI
77427 99238 NCCI
77427 99239 NCCI
77427 99281 NCCI
77427 99281 NCCI
77427 99283 NCCI
77427 99284 NCCI
77427 99284 NCCI
77427 99285 NCCI
77427 99291 NCCI
77427 99304 NCCI
77427 99305 NCCI
77427 99306 NCCI
77427 99307 NCCI
77427 99308 NCCI
77427 99309 NCCI
77427 99310 NCCI
77427 99315 NCCI
77427 99316 NCCI
77427 99318 NCCI
77427 99324 NCCI
77427 99325 NCCI
77427 99326 NCCI
77427 99327 NCCI
77427 99328 NCCI
77427 99334 NCCI
77427 99335 NCCI
77427 99336 NCCI
77427 99337 NCCI
77427 99342 NCCI
77427 99342 NCCI
77427 99344 NCCI
77427 99348 NCCI
77427 99349 NCCI
77427 99349 NCCI
77427 99350 NCCI
77427 99350 NCCI
77427 99354 NCCI
77427 99356 NCCI
77427 99357 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 127 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77427 99360 NCCI
77427 99455 NCCI
77427 99456 NCCI
77427 99460 NCCI
77427 99461 NCCI
77427 99462 NCCI
77427 99463 NCCI
77427 99464 NCCI
77427 99465 NCCI
77427 99466 NCCI
77427 99467 NCCI
77427 99468 NCCI
77427 99469 NCCI
77427 99471 NCCI
77427 99472 NCCI
77427 99475 NCCI
77427 99476 NCCI
77427 99477 NCCI
77427 99478 NCCI
77427 99479 NCCI
77427 99480 NCCI
77427 99485 NCCI
77427 G0270 NCCI
77427 G0271 NCCI
77427 G0339 NCCI
77427 G0340 NCCI
77427 G0459 NCCI
77427 M0064 NCCI
77431 11920 NCCI
77431 11921 NCCI
77431 16000 NCCI
77431 16020 NCCI
77431 16025 NCCI
77431 16030 NCCI
77431 36000 NCCI
77431 36410 NCCI
77431 36425 NCCI
77431 51701 NCCI
77431 51702 NCCI
77431 51703 NCCI
77431 76950 NCCI
77431 77427 NCCI
77431 90832 NCCI
77431 90833 NCCI
77431 90834 NCCI
77431 90836 NCCI
77431 90837 NCCI
Comprehensive ComponentCode Code Source
77431 90838 NCCI
77431 90839 NCCI
77431 90846 NCCI
77431 90847 NCCI
77431 96150 NCCI
77431 96151 NCCI
77431 96152 NCCI
77431 96153 NCCI
77431 96154 NCCI
77431 96360 NCCI
77431 96361 NCCI
77431 96365 NCCI
77431 96366 NCCI
77431 96367 NCCI
77431 96368 NCCI
77431 97802 NCCI
77431 97803 NCCI
77431 97804 NCCI
77431 99143 NCCI
77431 99144 NCCI
77431 99145 NCCI
77431 99183 NCCI
77431 99201 NCCI
77431 99202 NCCI
77431 99203 NCCI
77431 99204 NCCI
77431 99205 NCCI
77431 99211 NCCI
77431 99212 NCCI
77431 99213 NCCI
77431 99214 NCCI
77431 99215 NCCI
77431 99217 NCCI
77431 99218 NCCI
77431 99219 NCCI
77431 99220 NCCI
77431 99221 NCCI
77431 99222 NCCI
77431 99223 NCCI
77431 99224 NCCI
77431 99225 NCCI
77431 99226 NCCI
77431 99231 NCCI
77431 99232 NCCI
77431 99233 NCCI
77431 99234 NCCI
77431 99235 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 128 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77431 99236 NCCI
77431 99238 NCCI
77431 99239 NCCI
77431 99239 NCCI
77431 99281 NCCI
77431 99282 NCCI
77431 99283 NCCI
77431 99284 NCCI
77431 99285 NCCI
77431 99291 NCCI
77431 99304 NCCI
77431 99305 NCCI
77431 99306 NCCI
77431 99307 NCCI
77431 99308 NCCI
77431 99309 NCCI
77431 99310 NCCI
77431 99315 NCCI
77431 99316 NCCI
77431 99318 NCCI
77431 99324 NCCI
77431 99325 NCCI
77431 99326 NCCI
77431 99327 NCCI
77431 99328 NCCI
77431 99334 NCCI
77431 99335 NCCI
77431 99336 NCCI
77431 99337 NCCI
77431 99341 NCCI
77431 99341 NCCI
77431 99342 NCCI
77431 99347 NCCI
77431 99348 NCCI
77431 99349 NCCI
77431 99350 NCCI
77431 99350 NCCI
77431 99354 NCCI
77431 99355 NCCI
77431 99356 NCCI
77431 99357 NCCI
77431 99360 NCCI
77431 99455 NCCI
77431 99456 NCCI
77431 99460 NCCI
77431 99461 NCCI
77431 99462 NCCI
Comprehensive ComponentCode Code Source
77431 99463 NCCI
77431 99464 NCCI
77431 99465 NCCI
77431 99466 NCCI
77431 99467 NCCI
77431 99468 NCCI
77431 99469 NCCI
77431 99471 NCCI
77431 99472 NCCI
77431 99475 NCCI
77431 99476 NCCI
77431 99477 NCCI
77431 99478 NCCI
77431 99479 NCCI
77431 99480 NCCI
77431 99485 NCCI
77431 G0270 NCCI
77431 G0271 NCCI
77431 G0339 NCCI
77431 G0340 NCCI
77431 G0459 NCCI
77431 M0064 NCCI
77432 11920 NCCI
77432 11921 NCCI
77432 16000 NCCI
77432 16020 NCCI
77432 16025 NCCI
77432 16030 NCCI
77432 36000 NCCI
77432 36410 NCCI
77432 36425 NCCI
77432 51701 NCCI
77432 51702 NCCI
77432 51703 NCCI
77432 61781 NCCI
77432 61782 NCCI
77432 61783 NCCI
77432 77421 NCCI
77432 77431 NCCI
77432 77432 CPT
77432 77469 NCCI
77432 90832 NCCI
77432 90833 NCCI
77432 90834 NCCI
77432 90836 NCCI
77432 90837 NCCI
77432 90838 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 129 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77432 90839 NCCI
77432 90846 NCCI
77432 90847 NCCI
77432 96150 NCCI
77432 96151 NCCI
77432 96152 NCCI
77432 96153 NCCI
77432 96154 NCCI
77432 96360 NCCI
77432 96361 NCCI
77432 96365 NCCI
77432 96366 NCCI
77432 96367 NCCI
77432 96368 NCCI
77432 97802 NCCI
77432 97803 NCCI
77432 97804 NCCI
77432 99143 NCCI
77432 99144 NCCI
77432 99145 NCCI
77432 99183 NCCI
77432 99201 NCCI
77432 99202 NCCI
77432 99203 NCCI
77432 99204 NCCI
77432 99205 NCCI
77432 99211 NCCI
77432 99212 NCCI
77432 99213 NCCI
77432 99214 NCCI
77432 99215 NCCI
77432 99217 NCCI
77432 99218 NCCI
77432 99219 NCCI
77432 99220 NCCI
77432 99221 NCCI
77432 99222 NCCI
77432 99223 NCCI
77432 99224 NCCI
77432 99225 NCCI
77432 99226 NCCI
77432 99231 NCCI
77432 99232 NCCI
77432 99233 NCCI
77432 99238 NCCI
77432 99239 NCCI
77432 99281 NCCI
Comprehensive ComponentCode Code Source
77432 99283 NCCI
77432 99291 NCCI
77432 99291 NCCI
77432 99304 NCCI
77432 99305 NCCI
77432 99306 NCCI
77432 99307 NCCI
77432 99308 NCCI
77432 99309 NCCI
77432 99310 NCCI
77432 99315 NCCI
77432 99316 NCCI
77432 99318 NCCI
77432 99324 NCCI
77432 99325 NCCI
77432 99326 NCCI
77432 99327 NCCI
77432 99328 NCCI
77432 99334 NCCI
77432 99335 NCCI
77432 99336 NCCI
77432 99337 NCCI
77432 99341 NCCI
77432 99341 NCCI
77432 99342 NCCI
77432 99344 NCCI
77432 99345 NCCI
77432 99348 NCCI
77432 99349 NCCI
77432 99350 NCCI
77432 99350 NCCI
77432 99354 NCCI
77432 99356 NCCI
77432 99357 NCCI
77432 99360 NCCI
77432 99455 NCCI
77432 99456 NCCI
77432 99460 NCCI
77432 99461 NCCI
77432 99462 NCCI
77432 99463 NCCI
77432 99464 NCCI
77432 99465 NCCI
77432 99466 NCCI
77432 99467 NCCI
77432 99468 NCCI
77432 99469 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 130 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77432 99471 NCCI
77432 99472 NCCI
77432 99475 NCCI
77432 99476 NCCI
77432 99477 NCCI
77432 99478 NCCI
77432 99479 NCCI
77432 99480 NCCI
77432 99485 NCCI
77432 G0270 NCCI
77432 G0271 NCCI
77432 G0459 NCCI
77432 M0064 NCCI
77435 11920 NCCI
77435 11921 NCCI
77435 16000 NCCI
77435 16020 NCCI
77435 16025 NCCI
77435 16030 NCCI
77435 36000 NCCI
77435 36410 NCCI
77435 36425 NCCI
77435 51701 NCCI
77435 51702 NCCI
77435 51703 NCCI
77435 61781 NCCI
77435 61782 NCCI
77435 61783 NCCI
77435 77421 NCCI
77435 77427 NCCI
77435 77431 NCCI
77435 77432 NCCI
77435 77469 NCCI
77435 77470 NCCI
77435 90832 NCCI
77435 90833 NCCI
77435 90834 NCCI
77435 90836 NCCI
77435 90837 NCCI
77435 90838 NCCI
77435 90839 NCCI
77435 90846 NCCI
77435 90847 NCCI
77435 96150 NCCI
77435 96151 NCCI
77435 96152 NCCI
77435 96153 NCCI
Comprehensive ComponentCode Code Source
77435 96154 NCCI
77435 96360 NCCI
77435 96361 NCCI
77435 96365 NCCI
77435 96366 NCCI
77435 96367 NCCI
77435 96368 NCCI
77435 97802 NCCI
77435 97803 NCCI
77435 97804 NCCI
77435 99143 NCCI
77435 99144 NCCI
77435 99145 NCCI
77435 99183 NCCI
77435 99201 NCCI
77435 99202 NCCI
77435 99203 NCCI
77435 99204 NCCI
77435 99205 NCCI
77435 99211 NCCI
77435 99212 NCCI
77435 99213 NCCI
77435 99214 NCCI
77435 99215 NCCI
77435 99217 NCCI
77435 99218 NCCI
77435 99219 NCCI
77435 99220 NCCI
77435 99221 NCCI
77435 99222 NCCI
77435 99223 NCCI
77435 99224 NCCI
77435 99225 NCCI
77435 99226 NCCI
77435 99231 NCCI
77435 99232 NCCI
77435 99233 NCCI
77435 99234 NCCI
77435 99235 NCCI
77435 99236 NCCI
77435 99238 NCCI
77435 99239 NCCI
77435 99281 NCCI
77435 99282 NCCI
77435 99283 NCCI
77435 99284 NCCI
77435 99285 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 131 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77435 99291 NCCI
77435 99304 NCCI
77435 99305 NCCI
77435 99306 NCCI
77435 99307 NCCI
77435 99308 NCCI
77435 99309 NCCI
77435 99310 NCCI
77435 99315 NCCI
77435 99316 NCCI
77435 99318 NCCI
77435 99324 NCCI
77435 99325 NCCI
77435 99326 NCCI
77435 99327 NCCI
77435 99328 NCCI
77435 99334 NCCI
77435 99335 NCCI
77435 99336 NCCI
77435 99337 NCCI
77435 99341 NCCI
77435 99342 NCCI
77435 99343 NCCI
77435 99344 NCCI
77435 99345 NCCI
77435 99347 NCCI
77435 99348 NCCI
77435 99349 NCCI
77435 99350 NCCI
77435 99354 NCCI
77435 99355 NCCI
77435 99356 NCCI
77435 99357 NCCI
77435 99360 NCCI
77435 99455 NCCI
77435 99456 NCCI
77435 99460 NCCI
77435 99461 NCCI
77435 99462 NCCI
77435 99463 NCCI
77435 99464 NCCI
77435 99465 NCCI
77435 99466 NCCI
77435 99468 NCCI
77435 99469 NCCI
77435 99471 NCCI
77435 99472 NCCI
Comprehensive ComponentCode Code Source
77435 99475 NCCI
77435 99476 NCCI
77435 99477 NCCI
77435 99478 NCCI
77435 99479 NCCI
77435 99480 NCCI
77435 99485 NCCI
77435 G0270 NCCI
77435 G0271 NCCI
77435 G0459 NCCI
77435 M0064 NCCI
77469 0226T NCCI
77469 0288T NCCI
77469 11920 NCCI
77469 11921 NCCI
77469 16000 NCCI
77469 16020 NCCI
77469 16025 NCCI
77469 16030 NCCI
77469 36000 NCCI
77469 36410 NCCI
77469 36425 NCCI
77469 46600 NCCI
77469 51701 NCCI
77469 51702 NCCI
77469 51703 NCCI
77469 77470 NCCI
77469 90832 NCCI
77469 90833 NCCI
77469 90834 NCCI
77469 90836 NCCI
77469 90837 NCCI
77469 90838 NCCI
77469 90839 NCCI
77469 90846 NCCI
77469 90847 NCCI
77469 96150 NCCI
77469 96151 NCCI
77469 96152 NCCI
77469 96153 NCCI
77469 96154 NCCI
77469 96360 NCCI
77469 96361 NCCI
77469 96365 NCCI
77469 96366 NCCI
77469 96367 NCCI
77469 96368 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 132 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77469 97802 NCCI
77469 97803 NCCI
77469 97804 NCCI
77469 99143 NCCI
77469 99144 NCCI
77469 99145 NCCI
77469 99183 NCCI
77469 G0270 NCCI
77469 G0271 NCCI
77469 G0339 NCCI
77469 G0340 NCCI
77469 G0459 NCCI
77469 M0064 NCCI
77470 0226T NCCI
77470 0288T NCCI
77470 11920 NCCI
77470 11921 NCCI
77470 16000 NCCI
77470 16020 NCCI
77470 16025 NCCI
77470 16030 NCCI
77470 36000 NCCI
77470 36410 NCCI
77470 36425 NCCI
77470 46600 NCCI
77470 51701 NCCI
77470 51702 NCCI
77470 51703 NCCI
77470 77432 NCCI
77470 90832 NCCI
77470 90833 NCCI
77470 90834 NCCI
77470 90836 NCCI
77470 90837 NCCI
77470 90838 NCCI
77470 90839 NCCI
77470 90846 NCCI
77470 90847 NCCI
77470 96150 NCCI
77470 96151 NCCI
77470 96152 NCCI
77470 96153 NCCI
77470 96154 NCCI
77470 96360 NCCI
77470 96361 NCCI
77470 96365 NCCI
77470 96366 NCCI
Comprehensive ComponentCode Code Source
77470 96367 NCCI
77470 96368 NCCI
77470 97802 NCCI
77470 97803 NCCI
77470 97804 NCCI
77470 99143 NCCI
77470 99144 NCCI
77470 99145 NCCI
77470 99183 NCCI
77470 99201 NCCI
77470 99202 NCCI
77470 99203 NCCI
77470 99204 NCCI
77470 99205 NCCI
77470 99211 NCCI
77470 99212 NCCI
77470 99213 NCCI
77470 99214 NCCI
77470 99215 NCCI
77470 99217 NCCI
77470 99218 NCCI
77470 99219 NCCI
77470 99220 NCCI
77470 99221 NCCI
77470 99222 NCCI
77470 99223 NCCI
77470 99224 NCCI
77470 99225 NCCI
77470 99226 NCCI
77470 99231 NCCI
77470 99232 NCCI
77470 99233 NCCI
77470 99234 NCCI
77470 99235 NCCI
77470 99235 NCCI
77470 99238 NCCI
77470 99239 NCCI
77470 99281 NCCI
77470 99283 NCCI
77470 99283 NCCI
77470 99285 NCCI
77470 99304 NCCI
77470 99305 NCCI
77470 99306 NCCI
77470 99307 NCCI
77470 99308 NCCI
77470 99309 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 133 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77470 99310 NCCI
77470 99315 NCCI
77470 99316 NCCI
77470 99318 NCCI
77470 99324 NCCI
77470 99325 NCCI
77470 99326 NCCI
77470 99327 NCCI
77470 99328 NCCI
77470 99334 NCCI
77470 99335 NCCI
77470 99336 NCCI
77470 99337 NCCI
77470 99341 NCCI
77470 99341 NCCI
77470 99342 NCCI
77470 99343 NCCI
77470 99344 NCCI
77470 99344 NCCI
77470 99345 NCCI
77470 99347 NCCI
77470 99347 NCCI
77470 99348 NCCI
77470 99350 NCCI
77470 99354 NCCI
77470 99356 NCCI
77470 99357 NCCI
77470 99360 NCCI
77470 99455 NCCI
77470 99456 NCCI
77470 99460 NCCI
77470 99461 NCCI
77470 99462 NCCI
77470 99463 NCCI
77470 99464 NCCI
77470 99465 NCCI
77470 99466 NCCI
77470 99467 NCCI
77470 99468 NCCI
77470 99469 NCCI
77470 99471 NCCI
77470 99472 NCCI
77470 99475 NCCI
77470 99476 NCCI
77470 99477 NCCI
77470 99478 NCCI
77470 99479 NCCI
Comprehensive ComponentCode Code Source
77470 99480 NCCI
77470 99485 NCCI
77470 G0270 NCCI
77470 G0271 NCCI
77470 G0339 NCCI
77470 G0340 NCCI
77470 G0459 NCCI
77470 M0064 NCCI
77520 11920 NCCI
77520 11921 NCCI
77520 16000 NCCI
77520 16020 NCCI
77520 16025 NCCI
77520 16030 NCCI
77520 36000 NCCI
77520 36410 NCCI
77520 36425 NCCI
77520 51701 NCCI
77520 51702 NCCI
77520 51703 NCCI
77520 77371 NCCI
77520 77372 NCCI
77520 77373 NCCI
77520 77401 NCCI
77520 77402 NCCI
77520 77403 NCCI
77520 77404 NCCI
77520 77406 NCCI
77520 77407 NCCI
77520 77408 NCCI
77520 77409 NCCI
77520 77411 NCCI
77520 77412 NCCI
77520 77413 NCCI
77520 77414 NCCI
77520 77416 NCCI
77520 77520 CPT
77520 90832 NCCI
77520 90833 NCCI
77520 90834 NCCI
77520 90836 NCCI
77520 90837 NCCI
77520 90838 NCCI
77520 90839 NCCI
77520 90846 NCCI
77520 90847 NCCI
77520 96360 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 134 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77520 96361 NCCI
77520 96365 NCCI
77520 96366 NCCI
77520 96367 NCCI
77520 96368 NCCI
77520 97802 NCCI
77520 97803 NCCI
77520 97804 NCCI
77520 99143 NCCI
77520 99144 NCCI
77520 99145 NCCI
77520 99201 NCCI
77520 99202 NCCI
77520 99203 NCCI
77520 99204 NCCI
77520 99205 NCCI
77520 99211 NCCI
77520 99212 NCCI
77520 99213 NCCI
77520 99214 NCCI
77520 99215 NCCI
77520 99217 NCCI
77520 99218 NCCI
77520 99219 NCCI
77520 99220 NCCI
77520 99221 NCCI
77520 99222 NCCI
77520 99223 NCCI
77520 99224 NCCI
77520 99225 NCCI
77520 99226 NCCI
77520 99231 NCCI
77520 99232 NCCI
77520 99233 NCCI
77520 99234 NCCI
77520 99235 NCCI
77520 99236 NCCI
77520 99238 NCCI
77520 99239 NCCI
77520 99281 NCCI
77520 99282 NCCI
77520 99283 NCCI
77520 99284 NCCI
77520 99285 NCCI
77520 99291 NCCI
77520 99292 NCCI
77520 99304 NCCI
Comprehensive ComponentCode Code Source
77520 99305 NCCI
77520 99306 NCCI
77520 99307 NCCI
77520 99308 NCCI
77520 99309 NCCI
77520 99310 NCCI
77520 99315 NCCI
77520 99316 NCCI
77520 99318 NCCI
77520 99324 NCCI
77520 99325 NCCI
77520 99326 NCCI
77520 99327 NCCI
77520 99328 NCCI
77520 99334 NCCI
77520 99335 NCCI
77520 99336 NCCI
77520 99337 NCCI
77520 99341 NCCI
77520 99342 NCCI
77520 99343 NCCI
77520 99344 NCCI
77520 99345 NCCI
77520 99347 NCCI
77520 99348 NCCI
77520 99349 NCCI
77520 99350 NCCI
77520 99354 NCCI
77520 99355 NCCI
77520 99356 NCCI
77520 99357 NCCI
77520 99360 NCCI
77520 99455 NCCI
77520 99456 NCCI
77520 99460 NCCI
77520 99461 NCCI
77520 99462 NCCI
77520 99463 NCCI
77520 99464 NCCI
77520 99465 NCCI
77520 99466 NCCI
77520 99467 NCCI
77520 99468 NCCI
77520 99469 NCCI
77520 99471 NCCI
77520 99472 NCCI
77520 99475 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 135 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77520 99476 NCCI
77520 99477 NCCI
77520 99478 NCCI
77520 99479 NCCI
77520 99480 NCCI
77520 99485 NCCI
77520 G0251 NCCI
77520 G0339 NCCI
77520 G0340 NCCI
77520 G0459 NCCI
77520 M0064 NCCI
77522 11920 NCCI
77522 11921 NCCI
77522 16000 NCCI
77522 16020 NCCI
77522 16025 NCCI
77522 16030 NCCI
77522 36000 NCCI
77522 36410 NCCI
77522 36425 NCCI
77522 51701 NCCI
77522 51702 NCCI
77522 51703 NCCI
77522 77371 NCCI
77522 77372 NCCI
77522 77373 NCCI
77522 77401 NCCI
77522 77402 NCCI
77522 77403 NCCI
77522 77404 NCCI
77522 77406 NCCI
77522 77407 NCCI
77522 77408 NCCI
77522 77409 NCCI
77522 77411 NCCI
77522 77412 NCCI
77522 77413 NCCI
77522 77414 NCCI
77522 77416 NCCI
77522 77520 BCBST
77522 90832 NCCI
77522 90833 NCCI
77522 90834 NCCI
77522 90836 NCCI
77522 90837 NCCI
77522 90838 NCCI
77522 90839 NCCI
Comprehensive ComponentCode Code Source
77522 90846 NCCI
77522 90847 NCCI
77522 96360 NCCI
77522 96361 NCCI
77522 96365 NCCI
77522 96366 NCCI
77522 96367 NCCI
77522 96368 NCCI
77522 97802 NCCI
77522 97803 NCCI
77522 97804 NCCI
77522 99143 NCCI
77522 99144 NCCI
77522 99145 NCCI
77522 99201 NCCI
77522 99202 NCCI
77522 99203 NCCI
77522 99204 NCCI
77522 99205 NCCI
77522 99211 NCCI
77522 99212 NCCI
77522 99213 NCCI
77522 99214 NCCI
77522 99215 NCCI
77522 99217 NCCI
77522 99218 NCCI
77522 99219 NCCI
77522 99220 NCCI
77522 99221 NCCI
77522 99222 NCCI
77522 99223 NCCI
77522 99224 NCCI
77522 99225 NCCI
77522 99226 NCCI
77522 99231 NCCI
77522 99232 NCCI
77522 99233 NCCI
77522 99234 NCCI
77522 99235 NCCI
77522 99236 NCCI
77522 99238 NCCI
77522 99239 NCCI
77522 99281 NCCI
77522 99282 NCCI
77522 99283 NCCI
77522 99284 NCCI
77522 99285 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 136 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77522 99291 NCCI
77522 99292 NCCI
77522 99304 NCCI
77522 99305 NCCI
77522 99306 NCCI
77522 99307 NCCI
77522 99308 NCCI
77522 99309 NCCI
77522 99310 NCCI
77522 99315 NCCI
77522 99316 NCCI
77522 99318 NCCI
77522 99324 NCCI
77522 99325 NCCI
77522 99326 NCCI
77522 99327 NCCI
77522 99328 NCCI
77522 99334 NCCI
77522 99335 NCCI
77522 99336 NCCI
77522 99337 NCCI
77522 99341 NCCI
77522 99342 NCCI
77522 99343 NCCI
77522 99344 NCCI
77522 99345 NCCI
77522 99347 NCCI
77522 99348 NCCI
77522 99349 NCCI
77522 99350 NCCI
77522 99354 NCCI
77522 99355 NCCI
77522 99356 NCCI
77522 99357 NCCI
77522 99360 NCCI
77522 99455 NCCI
77522 99456 NCCI
77522 99460 NCCI
77522 99461 NCCI
77522 99462 NCCI
77522 99463 NCCI
77522 99464 NCCI
77522 99465 NCCI
77522 99466 NCCI
77522 99467 NCCI
77522 99468 NCCI
77522 99469 NCCI
Comprehensive ComponentCode Code Source
77522 99471 NCCI
77522 99472 NCCI
77522 99475 NCCI
77522 99476 NCCI
77522 99477 NCCI
77522 99478 NCCI
77522 99479 NCCI
77522 99480 NCCI
77522 99485 NCCI
77522 G0251 NCCI
77522 G0339 NCCI
77522 G0340 NCCI
77522 G0459 NCCI
77522 M0064 NCCI
77523 11920 NCCI
77523 11921 NCCI
77523 16000 NCCI
77523 16020 NCCI
77523 16025 NCCI
77523 16030 NCCI
77523 36000 NCCI
77523 36410 NCCI
77523 36425 NCCI
77523 51701 NCCI
77523 51702 NCCI
77523 51703 NCCI
77523 77371 NCCI
77523 77372 NCCI
77523 77373 NCCI
77523 77401 NCCI
77523 77402 NCCI
77523 77403 NCCI
77523 77403 BCBST
77523 77404 BCBST
77523 77404 NCCI
77523 77406 NCCI
77523 77406 BCBST
77523 77407 NCCI
77523 77408 NCCI
77523 77409 NCCI
77523 77411 NCCI
77523 77412 NCCI
77523 77413 NCCI
77523 77414 NCCI
77523 77416 NCCI
77523 77520 NCCI
77523 77522 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 137 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77523 77523 CPT
77523 90832 NCCI
77523 90833 NCCI
77523 90834 NCCI
77523 90836 NCCI
77523 90837 NCCI
77523 90838 NCCI
77523 90839 NCCI
77523 90846 NCCI
77523 90847 NCCI
77523 96360 NCCI
77523 96361 NCCI
77523 96365 NCCI
77523 96366 NCCI
77523 96367 NCCI
77523 96368 NCCI
77523 97802 NCCI
77523 97803 NCCI
77523 97804 NCCI
77523 99143 NCCI
77523 99144 NCCI
77523 99145 NCCI
77523 99201 NCCI
77523 99202 NCCI
77523 99203 NCCI
77523 99204 NCCI
77523 99205 NCCI
77523 99211 NCCI
77523 99212 NCCI
77523 99213 NCCI
77523 99214 NCCI
77523 99215 NCCI
77523 99217 NCCI
77523 99218 NCCI
77523 99219 NCCI
77523 99220 NCCI
77523 99221 NCCI
77523 99222 NCCI
77523 99223 NCCI
77523 99224 NCCI
77523 99225 NCCI
77523 99226 NCCI
77523 99231 NCCI
77523 99232 NCCI
77523 99233 NCCI
77523 99234 NCCI
77523 99235 NCCI
Comprehensive ComponentCode Code Source
77523 99236 NCCI
77523 99238 NCCI
77523 99239 NCCI
77523 99281 NCCI
77523 99282 NCCI
77523 99283 NCCI
77523 99284 NCCI
77523 99285 NCCI
77523 99291 NCCI
77523 99292 NCCI
77523 99304 NCCI
77523 99305 NCCI
77523 99306 NCCI
77523 99307 NCCI
77523 99308 NCCI
77523 99309 NCCI
77523 99310 NCCI
77523 99315 NCCI
77523 99316 NCCI
77523 99318 NCCI
77523 99324 NCCI
77523 99325 NCCI
77523 99326 NCCI
77523 99327 NCCI
77523 99328 NCCI
77523 99334 NCCI
77523 99335 NCCI
77523 99336 NCCI
77523 99337 NCCI
77523 99341 NCCI
77523 99342 NCCI
77523 99343 NCCI
77523 99344 NCCI
77523 99345 NCCI
77523 99347 NCCI
77523 99348 NCCI
77523 99349 NCCI
77523 99350 NCCI
77523 99354 NCCI
77523 99355 NCCI
77523 99356 NCCI
77523 99357 NCCI
77523 99360 NCCI
77523 99455 NCCI
77523 99456 NCCI
77523 99460 NCCI
77523 99461 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 138 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77523 99462 NCCI
77523 99463 NCCI
77523 99464 NCCI
77523 99465 NCCI
77523 99466 NCCI
77523 99467 NCCI
77523 99468 NCCI
77523 99469 NCCI
77523 99471 NCCI
77523 99472 NCCI
77523 99475 NCCI
77523 99476 NCCI
77523 99477 NCCI
77523 99478 NCCI
77523 99479 NCCI
77523 99480 NCCI
77523 99485 NCCI
77523 G0251 NCCI
77523 G0339 NCCI
77523 G0340 NCCI
77523 G0459 NCCI
77523 M0064 NCCI
77525 11920 NCCI
77525 11921 NCCI
77525 16000 NCCI
77525 16020 NCCI
77525 16025 NCCI
77525 16030 NCCI
77525 36000 NCCI
77525 36410 NCCI
77525 36425 NCCI
77525 51701 NCCI
77525 51702 NCCI
77525 51703 NCCI
77525 77371 NCCI
77525 77372 NCCI
77525 77373 NCCI
77525 77401 NCCI
77525 77402 NCCI
77525 77403 NCCI
77525 77404 NCCI
77525 77406 NCCI
77525 77407 NCCI
77525 77408 NCCI
77525 77409 NCCI
77525 77411 NCCI
77525 77412 NCCI
Comprehensive ComponentCode Code Source
77525 77413 NCCI
77525 77414 NCCI
77525 77416 NCCI
77525 77520 BCBST
77525 77522 BCBST
77525 77523 BCBST
77525 77525 CPT
77525 90832 NCCI
77525 90833 NCCI
77525 90834 NCCI
77525 90836 NCCI
77525 90837 NCCI
77525 90838 NCCI
77525 90839 NCCI
77525 90846 NCCI
77525 90847 NCCI
77525 96360 NCCI
77525 96361 NCCI
77525 96365 NCCI
77525 96366 NCCI
77525 96367 NCCI
77525 96368 NCCI
77525 97802 NCCI
77525 97803 NCCI
77525 97804 NCCI
77525 99143 NCCI
77525 99144 NCCI
77525 99145 NCCI
77525 99201 NCCI
77525 99202 NCCI
77525 99203 NCCI
77525 99204 NCCI
77525 99205 NCCI
77525 99211 NCCI
77525 99212 NCCI
77525 99213 NCCI
77525 99214 NCCI
77525 99215 NCCI
77525 99217 NCCI
77525 99218 NCCI
77525 99219 NCCI
77525 99220 NCCI
77525 99221 NCCI
77525 99222 NCCI
77525 99223 NCCI
77525 99224 NCCI
77525 99225 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 139 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77525 99226 NCCI
77525 99231 NCCI
77525 99232 NCCI
77525 99233 NCCI
77525 99234 NCCI
77525 99235 NCCI
77525 99236 NCCI
77525 99238 NCCI
77525 99239 NCCI
77525 99281 NCCI
77525 99282 NCCI
77525 99283 NCCI
77525 99284 NCCI
77525 99285 NCCI
77525 99291 NCCI
77525 99292 NCCI
77525 99304 NCCI
77525 99305 NCCI
77525 99306 NCCI
77525 99307 NCCI
77525 99308 NCCI
77525 99309 NCCI
77525 99310 NCCI
77525 99315 NCCI
77525 99316 NCCI
77525 99318 NCCI
77525 99324 NCCI
77525 99325 NCCI
77525 99326 NCCI
77525 99327 NCCI
77525 99328 NCCI
77525 99334 NCCI
77525 99335 NCCI
77525 99336 NCCI
77525 99337 NCCI
77525 99341 NCCI
77525 99342 NCCI
77525 99343 NCCI
77525 99344 NCCI
77525 99345 NCCI
77525 99347 NCCI
77525 99348 NCCI
77525 99349 NCCI
77525 99350 NCCI
77525 99354 NCCI
77525 99355 NCCI
77525 99356 NCCI
Comprehensive ComponentCode Code Source
77525 99357 NCCI
77525 99360 NCCI
77525 99455 NCCI
77525 99456 NCCI
77525 99460 NCCI
77525 99461 NCCI
77525 99462 NCCI
77525 99463 NCCI
77525 99464 NCCI
77525 99465 NCCI
77525 99466 NCCI
77525 99467 NCCI
77525 99468 NCCI
77525 99469 NCCI
77525 99471 NCCI
77525 99472 NCCI
77525 99475 NCCI
77525 99476 NCCI
77525 99477 NCCI
77525 99478 NCCI
77525 99479 NCCI
77525 99480 NCCI
77525 99485 NCCI
77525 G0251 NCCI
77525 G0339 NCCI
77525 G0340 NCCI
77525 G0459 NCCI
77525 M0064 NCCI
77600 11920 NCCI
77600 11921 NCCI
77600 16000 NCCI
77600 16020 NCCI
77600 16025 NCCI
77600 16030 NCCI
77600 36000 NCCI
77600 36410 NCCI
77600 36425 NCCI
77600 51701 NCCI
77600 51702 NCCI
77600 51703 NCCI
77600 77261 NCCI
77600 77262 NCCI
77600 77263 NCCI
77600 77300 NCCI
77600 77331 NCCI
77600 77332 NCCI
77600 77333 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 140 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77600 77334 NCCI
77600 77336 NCCI
77600 77370 NCCI
77600 77610 NCCI
77600 77615 NCCI
77600 77620 NCCI
77600 90832 NCCI
77600 90833 NCCI
77600 90834 NCCI
77600 90836 NCCI
77600 90837 NCCI
77600 90838 NCCI
77600 90839 NCCI
77600 90846 NCCI
77600 90847 NCCI
77600 93000 NCCI
77600 93005 NCCI
77600 93010 NCCI
77600 93040 NCCI
77600 93041 NCCI
77600 93042 NCCI
77600 94770 NCCI
77600 96360 NCCI
77600 96361 NCCI
77600 96365 NCCI
77600 96366 NCCI
77600 96367 NCCI
77600 96368 NCCI
77600 97024 NCCI
77600 97032 NCCI
77600 97035 NCCI
77600 97802 NCCI
77600 97803 NCCI
77600 97804 NCCI
77600 99143 NCCI
77600 99144 NCCI
77600 99145 NCCI
77600 99148 NCCI
77600 99149 NCCI
77600 99150 NCCI
77600 99201 NCCI
77600 99202 NCCI
77600 99203 NCCI
77600 99204 NCCI
77600 99205 NCCI
77600 99211 NCCI
77600 99212 NCCI
Comprehensive ComponentCode Code Source
77600 99213 NCCI
77600 99214 NCCI
77600 99215 NCCI
77600 99217 NCCI
77600 99218 NCCI
77600 99219 NCCI
77600 99220 NCCI
77600 99221 NCCI
77600 99222 NCCI
77600 99223 NCCI
77600 99224 NCCI
77600 99225 NCCI
77600 99226 NCCI
77600 99231 NCCI
77600 99232 NCCI
77600 99233 NCCI
77600 99234 NCCI
77600 99235 NCCI
77600 99236 NCCI
77600 99238 NCCI
77600 99239 NCCI
77600 99241 Retained NCCI
77600 99242 Retained NCCI
77600 99243 Retained NCCI
77600 99244 Retained NCCI
77600 99245 Retained NCCI
77600 99251 Retained NCCI
77600 99252 Retained NCCI
77600 99253 Retained NCCI
77600 99254 Retained NCCI
77600 99255 Retained NCCI
77600 99281 NCCI
77600 99282 NCCI
77600 99283 NCCI
77600 99284 NCCI
77600 99285 NCCI
77600 99291 NCCI
77600 99292 NCCI
77600 99304 NCCI
77600 99305 NCCI
77600 99306 NCCI
77600 99307 NCCI
77600 99308 NCCI
77600 99309 NCCI
77600 99310 NCCI
77600 99315 NCCI
77600 99316 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 141 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77600 99318 NCCI
77600 99324 NCCI
77600 99325 NCCI
77600 99326 NCCI
77600 99327 NCCI
77600 99328 NCCI
77600 99334 NCCI
77600 99335 NCCI
77600 99336 NCCI
77600 99337 NCCI
77600 99341 NCCI
77600 99342 NCCI
77600 99343 NCCI
77600 99344 NCCI
77600 99345 NCCI
77600 99347 NCCI
77600 99348 NCCI
77600 99349 NCCI
77600 99350 NCCI
77600 99354 NCCI
77600 99355 NCCI
77600 99356 NCCI
77600 99357 NCCI
77600 99360 NCCI
77600 99455 NCCI
77600 99456 NCCI
77600 99460 NCCI
77600 99461 NCCI
77600 99462 NCCI
77600 99463 NCCI
77600 99464 NCCI
77600 99465 NCCI
77600 99466 NCCI
77600 99467 NCCI
77600 99468 NCCI
77600 99469 NCCI
77600 99471 NCCI
77600 99472 NCCI
77600 99475 NCCI
77600 99476 NCCI
77600 99477 NCCI
77600 99478 NCCI
77600 99479 NCCI
77600 99480 NCCI
77600 99485 NCCI
77600 G0281 NCCI
77600 G0283 NCCI
Comprehensive ComponentCode Code Source
77600 G0406 NCCI
77600 G0407 NCCI
77600 G0408 NCCI
77600 G0425 NCCI
77600 G0426 NCCI
77600 G0427 NCCI
77600 G0459 NCCI
77600 J0670 NCCI
77600 J2001 NCCI
77600 M0064 NCCI
77605 11920 NCCI
77605 11921 NCCI
77605 16000 NCCI
77605 16020 NCCI
77605 16025 NCCI
77605 16030 NCCI
77605 36000 NCCI
77605 36410 NCCI
77605 36425 NCCI
77605 51701 NCCI
77605 51702 NCCI
77605 51703 NCCI
77605 77261 NCCI
77605 77262 NCCI
77605 77263 NCCI
77605 77300 NCCI
77605 77331 NCCI
77605 77332 NCCI
77605 77333 NCCI
77605 77334 NCCI
77605 77336 NCCI
77605 77370 NCCI
77605 77610 NCCI
77605 77615 NCCI
77605 77620 NCCI
77605 90832 NCCI
77605 90833 NCCI
77605 90834 NCCI
77605 90836 NCCI
77605 90837 NCCI
77605 90838 NCCI
77605 90839 NCCI
77605 90846 NCCI
77605 90847 NCCI
77605 93000 NCCI
77605 93005 NCCI
77605 93010 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 142 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77605 93040 NCCI
77605 93041 NCCI
77605 93042 NCCI
77605 94770 NCCI
77605 96360 NCCI
77605 96361 NCCI
77605 96365 NCCI
77605 96366 NCCI
77605 96367 NCCI
77605 96368 NCCI
77605 97024 NCCI
77605 97032 NCCI
77605 97035 NCCI
77605 97802 NCCI
77605 97803 NCCI
77605 97804 NCCI
77605 99143 NCCI
77605 99144 NCCI
77605 99145 NCCI
77605 99148 NCCI
77605 99149 NCCI
77605 99150 NCCI
77605 99201 NCCI
77605 99202 NCCI
77605 99203 NCCI
77605 99204 NCCI
77605 99205 NCCI
77605 99211 NCCI
77605 99212 NCCI
77605 99213 NCCI
77605 99214 NCCI
77605 99215 NCCI
77605 99217 NCCI
77605 99218 NCCI
77605 99219 NCCI
77605 99220 NCCI
77605 99221 NCCI
77605 99222 NCCI
77605 99223 NCCI
77605 99224 NCCI
77605 99225 NCCI
77605 99226 NCCI
77605 99231 NCCI
77605 99232 NCCI
77605 99233 NCCI
77605 99234 NCCI
77605 99235 NCCI
Comprehensive ComponentCode Code Source
77605 99236 NCCI
77605 99238 NCCI
77605 99239 NCCI
77605 99241 Retained NCCI
77605 99242 Retained NCCI
77605 99243 Retained NCCI
77605 99244 Retained NCCI
77605 99245 Retained NCCI
77605 99251 Retained NCCI
77605 99252 Retained NCCI
77605 99253 Retained NCCI
77605 99254 Retained NCCI
77605 99255 Retained NCCI
77605 99281 NCCI
77605 99282 NCCI
77605 99283 NCCI
77605 99284 NCCI
77605 99285 NCCI
77605 99291 NCCI
77605 99292 NCCI
77605 99304 NCCI
77605 99305 NCCI
77605 99306 NCCI
77605 99307 NCCI
77605 99308 NCCI
77605 99309 NCCI
77605 99310 NCCI
77605 99315 NCCI
77605 99316 NCCI
77605 99318 NCCI
77605 99324 NCCI
77605 99325 NCCI
77605 99326 NCCI
77605 99327 NCCI
77605 99328 NCCI
77605 99334 NCCI
77605 99335 NCCI
77605 99336 NCCI
77605 99337 NCCI
77605 99341 NCCI
77605 99342 NCCI
77605 99343 NCCI
77605 99344 NCCI
77605 99345 NCCI
77605 99347 NCCI
77605 99348 NCCI
77605 99349 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 143 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77605 99350 NCCI
77605 99354 NCCI
77605 99355 NCCI
77605 99356 NCCI
77605 99357 NCCI
77605 99360 NCCI
77605 99455 NCCI
77605 99456 NCCI
77605 99460 NCCI
77605 99461 NCCI
77605 99462 NCCI
77605 99463 NCCI
77605 99464 NCCI
77605 99465 NCCI
77605 99466 NCCI
77605 99467 NCCI
77605 99468 NCCI
77605 99469 NCCI
77605 99471 NCCI
77605 99472 NCCI
77605 99475 NCCI
77605 99476 NCCI
77605 99477 NCCI
77605 99478 NCCI
77605 99479 NCCI
77605 99480 NCCI
77605 99485 NCCI
77605 G0281 NCCI
77605 G0283 NCCI
77605 G0406 NCCI
77605 G0407 NCCI
77605 G0408 NCCI
77605 G0425 NCCI
77605 G0426 NCCI
77605 G0427 NCCI
77605 G0459 NCCI
77605 J0670 NCCI
77605 J2001 NCCI
77605 M0064 NCCI
77610 11920 NCCI
77610 11921 NCCI
77610 16000 NCCI
77610 16020 NCCI
77610 16025 NCCI
77610 16030 NCCI
77610 36000 NCCI
77610 36410 NCCI
Comprehensive ComponentCode Code Source
77610 36425 NCCI
77610 51701 NCCI
77610 51702 NCCI
77610 51703 NCCI
77610 77261 NCCI
77610 77262 NCCI
77610 77263 NCCI
77610 77300 NCCI
77610 77331 NCCI
77610 77332 NCCI
77610 77333 NCCI
77610 77334 NCCI
77610 77336 NCCI
77610 77370 NCCI
77610 77610 CPT
77610 77620 NCCI
77610 90832 NCCI
77610 90833 NCCI
77610 90834 NCCI
77610 90836 NCCI
77610 90837 NCCI
77610 90838 NCCI
77610 90839 NCCI
77610 90846 NCCI
77610 90847 NCCI
77610 93000 NCCI
77610 93005 NCCI
77610 93010 NCCI
77610 93040 NCCI
77610 93041 NCCI
77610 93042 NCCI
77610 94770 NCCI
77610 96360 NCCI
77610 96361 NCCI
77610 96365 NCCI
77610 96366 NCCI
77610 96367 NCCI
77610 96368 NCCI
77610 97024 NCCI
77610 97032 NCCI
77610 97035 NCCI
77610 97802 NCCI
77610 97803 NCCI
77610 97804 NCCI
77610 99143 NCCI
77610 99144 NCCI
77610 99145 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 144 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77610 99148 NCCI
77610 99149 NCCI
77610 99150 NCCI
77610 99201 NCCI
77610 99202 NCCI
77610 99203 NCCI
77610 99204 NCCI
77610 99205 NCCI
77610 99211 NCCI
77610 99212 NCCI
77610 99213 NCCI
77610 99214 NCCI
77610 99215 NCCI
77610 99217 NCCI
77610 99218 NCCI
77610 99219 NCCI
77610 99220 NCCI
77610 99221 NCCI
77610 99222 NCCI
77610 99223 NCCI
77610 99224 NCCI
77610 99225 NCCI
77610 99226 NCCI
77610 99231 NCCI
77610 99232 NCCI
77610 99233 NCCI
77610 99234 NCCI
77610 99235 NCCI
77610 99236 NCCI
77610 99238 NCCI
77610 99239 NCCI
77610 99241 Retained NCCI
77610 99242 Retained NCCI
77610 99243 Retained NCCI
77610 99244 Retained NCCI
77610 99245 Retained NCCI
77610 99251 Retained NCCI
77610 99252 Retained NCCI
77610 99253 Retained NCCI
77610 99254 Retained NCCI
77610 99255 Retained NCCI
77610 99281 NCCI
77610 99282 NCCI
77610 99283 NCCI
77610 99284 NCCI
77610 99285 NCCI
77610 99291 NCCI
Comprehensive ComponentCode Code Source
77610 99292 NCCI
77610 99304 NCCI
77610 99305 NCCI
77610 99306 NCCI
77610 99307 NCCI
77610 99308 NCCI
77610 99309 NCCI
77610 99310 NCCI
77610 99315 NCCI
77610 99316 NCCI
77610 99318 NCCI
77610 99324 NCCI
77610 99325 NCCI
77610 99326 NCCI
77610 99327 NCCI
77610 99328 NCCI
77610 99334 NCCI
77610 99335 NCCI
77610 99336 NCCI
77610 99337 NCCI
77610 99341 NCCI
77610 99342 NCCI
77610 99343 NCCI
77610 99344 NCCI
77610 99345 NCCI
77610 99347 NCCI
77610 99348 NCCI
77610 99349 NCCI
77610 99350 NCCI
77610 99354 NCCI
77610 99355 NCCI
77610 99356 NCCI
77610 99357 NCCI
77610 99360 NCCI
77610 99455 NCCI
77610 99456 NCCI
77610 99460 NCCI
77610 99461 NCCI
77610 99462 NCCI
77610 99463 NCCI
77610 99464 NCCI
77610 99465 NCCI
77610 99466 NCCI
77610 99467 NCCI
77610 99468 NCCI
77610 99469 NCCI
77610 99471 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 145 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77610 99472 NCCI
77610 99475 NCCI
77610 99476 NCCI
77610 99477 NCCI
77610 99478 NCCI
77610 99479 NCCI
77610 99480 NCCI
77610 99485 NCCI
77610 G0281 NCCI
77610 G0283 NCCI
77610 G0406 NCCI
77610 G0407 NCCI
77610 G0408 NCCI
77610 G0425 NCCI
77610 G0426 NCCI
77610 G0427 NCCI
77610 G0459 NCCI
77610 J0670 NCCI
77610 J2001 NCCI
77610 M0064 NCCI
77615 11920 NCCI
77615 11921 NCCI
77615 16000 NCCI
77615 16020 NCCI
77615 16025 NCCI
77615 16030 NCCI
77615 36000 NCCI
77615 36410 NCCI
77615 36425 NCCI
77615 51701 NCCI
77615 51702 NCCI
77615 51703 NCCI
77615 77261 NCCI
77615 77262 NCCI
77615 77263 NCCI
77615 77300 NCCI
77615 77331 NCCI
77615 77332 NCCI
77615 77333 NCCI
77615 77334 NCCI
77615 77336 NCCI
77615 77370 NCCI
77615 77610 NCCI
77615 77615 CPT
77615 77620 NCCI
77615 90832 NCCI
77615 90833 NCCI
Comprehensive ComponentCode Code Source
77615 90834 NCCI
77615 90836 NCCI
77615 90837 NCCI
77615 90838 NCCI
77615 90839 NCCI
77615 90846 NCCI
77615 90847 NCCI
77615 93000 NCCI
77615 93005 NCCI
77615 93010 NCCI
77615 93040 NCCI
77615 93041 NCCI
77615 93042 NCCI
77615 94770 NCCI
77615 96360 NCCI
77615 96361 NCCI
77615 96365 NCCI
77615 96366 NCCI
77615 96367 NCCI
77615 96368 NCCI
77615 97024 NCCI
77615 97032 NCCI
77615 97035 NCCI
77615 97802 NCCI
77615 97803 NCCI
77615 97804 NCCI
77615 99143 NCCI
77615 99144 NCCI
77615 99145 NCCI
77615 99148 NCCI
77615 99149 NCCI
77615 99150 NCCI
77615 99201 NCCI
77615 99202 NCCI
77615 99203 NCCI
77615 99204 NCCI
77615 99205 NCCI
77615 99211 NCCI
77615 99212 NCCI
77615 99213 NCCI
77615 99214 NCCI
77615 99215 NCCI
77615 99217 NCCI
77615 99218 NCCI
77615 99219 NCCI
77615 99220 NCCI
77615 99221 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 146 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77615 99222 NCCI
77615 99223 NCCI
77615 99224 NCCI
77615 99225 NCCI
77615 99226 NCCI
77615 99231 NCCI
77615 99232 NCCI
77615 99233 NCCI
77615 99234 NCCI
77615 99235 NCCI
77615 99236 NCCI
77615 99238 NCCI
77615 99239 NCCI
77615 99241 Retained NCCI
77615 99242 Retained NCCI
77615 99243 Retained NCCI
77615 99244 Retained NCCI
77615 99245 Retained NCCI
77615 99251 Retained NCCI
77615 99252 Retained NCCI
77615 99253 Retained NCCI
77615 99254 Retained NCCI
77615 99255 Retained NCCI
77615 99281 NCCI
77615 99282 NCCI
77615 99283 NCCI
77615 99284 NCCI
77615 99285 NCCI
77615 99291 NCCI
77615 99292 NCCI
77615 99304 NCCI
77615 99305 NCCI
77615 99306 NCCI
77615 99307 NCCI
77615 99308 NCCI
77615 99309 NCCI
77615 99310 NCCI
77615 99315 NCCI
77615 99316 NCCI
77615 99318 NCCI
77615 99324 NCCI
77615 99325 NCCI
77615 99326 NCCI
77615 99327 NCCI
77615 99328 NCCI
77615 99334 NCCI
77615 99335 NCCI
Comprehensive ComponentCode Code Source
77615 99336 NCCI
77615 99337 NCCI
77615 99341 NCCI
77615 99342 NCCI
77615 99343 NCCI
77615 99344 NCCI
77615 99345 NCCI
77615 99347 NCCI
77615 99348 NCCI
77615 99349 NCCI
77615 99350 NCCI
77615 99354 NCCI
77615 99355 NCCI
77615 99356 NCCI
77615 99357 NCCI
77615 99360 NCCI
77615 99455 NCCI
77615 99456 NCCI
77615 99460 NCCI
77615 99461 NCCI
77615 99462 NCCI
77615 99463 NCCI
77615 99464 NCCI
77615 99465 NCCI
77615 99466 NCCI
77615 99467 NCCI
77615 99468 NCCI
77615 99469 NCCI
77615 99471 NCCI
77615 99472 NCCI
77615 99475 NCCI
77615 99476 NCCI
77615 99477 NCCI
77615 99478 NCCI
77615 99479 NCCI
77615 99480 NCCI
77615 99485 NCCI
77615 G0281 NCCI
77615 G0283 NCCI
77615 G0406 NCCI
77615 G0407 NCCI
77615 G0408 NCCI
77615 G0425 NCCI
77615 G0426 NCCI
77615 G0427 NCCI
77615 G0459 NCCI
77615 J0670 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 147 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77615 J2001 NCCI
77615 M0064 NCCI
77620 11920 NCCI
77620 11921 NCCI
77620 16000 NCCI
77620 16020 NCCI
77620 16025 NCCI
77620 16030 NCCI
77620 36000 NCCI
77620 36410 NCCI
77620 36425 NCCI
77620 51701 NCCI
77620 51702 NCCI
77620 51703 NCCI
77620 77261 NCCI
77620 77262 NCCI
77620 77263 NCCI
77620 77300 NCCI
77620 77331 NCCI
77620 77332 NCCI
77620 77333 NCCI
77620 77334 NCCI
77620 77336 NCCI
77620 77370 NCCI
77620 77620 CPT
77620 90832 NCCI
77620 90833 NCCI
77620 90834 NCCI
77620 90836 NCCI
77620 90837 NCCI
77620 90838 NCCI
77620 90839 NCCI
77620 90846 NCCI
77620 90847 NCCI
77620 96360 NCCI
77620 96361 NCCI
77620 96365 NCCI
77620 96366 NCCI
77620 96367 NCCI
77620 96368 NCCI
77620 97024 NCCI
77620 97032 NCCI
77620 97035 NCCI
77620 97802 NCCI
77620 97803 NCCI
77620 97804 NCCI
77620 99143 NCCI
Comprehensive ComponentCode Code Source
77620 99144 NCCI
77620 99145 NCCI
77620 99201 NCCI
77620 99202 NCCI
77620 99203 NCCI
77620 99204 NCCI
77620 99205 NCCI
77620 99211 NCCI
77620 99212 NCCI
77620 99213 NCCI
77620 99214 NCCI
77620 99215 NCCI
77620 99217 NCCI
77620 99218 NCCI
77620 99219 NCCI
77620 99220 NCCI
77620 99221 NCCI
77620 99222 NCCI
77620 99223 NCCI
77620 99224 NCCI
77620 99225 NCCI
77620 99226 NCCI
77620 99231 NCCI
77620 99232 NCCI
77620 99233 NCCI
77620 99234 NCCI
77620 99235 NCCI
77620 99236 NCCI
77620 99238 NCCI
77620 99239 NCCI
77620 99241 Retained NCCI
77620 99242 Retained NCCI
77620 99243 Retained NCCI
77620 99244 Retained NCCI
77620 99245 Retained NCCI
77620 99251 Retained NCCI
77620 99252 Retained NCCI
77620 99253 Retained NCCI
77620 99254 Retained NCCI
77620 99255 Retained NCCI
77620 99281 NCCI
77620 99282 NCCI
77620 99283 NCCI
77620 99284 NCCI
77620 99285 NCCI
77620 99291 NCCI
77620 99292 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 148 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77620 99304 NCCI
77620 99305 NCCI
77620 99306 NCCI
77620 99307 NCCI
77620 99308 NCCI
77620 99309 NCCI
77620 99310 NCCI
77620 99315 NCCI
77620 99316 NCCI
77620 99318 NCCI
77620 99324 NCCI
77620 99325 NCCI
77620 99326 NCCI
77620 99327 NCCI
77620 99328 NCCI
77620 99334 NCCI
77620 99335 NCCI
77620 99336 NCCI
77620 99337 NCCI
77620 99341 NCCI
77620 99342 NCCI
77620 99343 NCCI
77620 99344 NCCI
77620 99345 NCCI
77620 99347 NCCI
77620 99348 NCCI
77620 99349 NCCI
77620 99350 NCCI
77620 99354 NCCI
77620 99355 NCCI
77620 99356 NCCI
77620 99357 NCCI
77620 99360 NCCI
77620 99455 NCCI
77620 99456 NCCI
77620 99460 NCCI
77620 99461 NCCI
77620 99462 NCCI
77620 99463 NCCI
77620 99464 NCCI
77620 99465 NCCI
77620 99466 NCCI
77620 99467 NCCI
77620 99468 NCCI
77620 99469 NCCI
77620 99471 NCCI
77620 99472 NCCI
Comprehensive ComponentCode Code Source
77620 99475 NCCI
77620 99476 NCCI
77620 99477 NCCI
77620 99478 NCCI
77620 99479 NCCI
77620 99480 NCCI
77620 99485 NCCI
77620 G0281 NCCI
77620 G0283 NCCI
77620 G0406 NCCI
77620 G0407 NCCI
77620 G0408 NCCI
77620 G0425 NCCI
77620 G0426 NCCI
77620 G0427 NCCI
77620 G0459 NCCI
77620 J0670 NCCI
77620 J2001 NCCI
77620 M0064 NCCI
77750 0213T NCCI
77750 0216T NCCI
77750 0228T NCCI
77750 0230T NCCI
77750 11920 NCCI
77750 11921 NCCI
77750 12001 NCCI
77750 12002 NCCI
77750 12004 NCCI
77750 12005 NCCI
77750 12006 NCCI
77750 12007 NCCI
77750 12011 NCCI
77750 12013 NCCI
77750 12014 NCCI
77750 12015 NCCI
77750 12016 NCCI
77750 12017 NCCI
77750 12018 NCCI
77750 12020 NCCI
77750 12021 NCCI
77750 12031 NCCI
77750 12032 NCCI
77750 12034 NCCI
77750 12035 NCCI
77750 12036 NCCI
77750 12037 NCCI
77750 12041 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 149 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77750 12042 NCCI
77750 12044 NCCI
77750 12045 NCCI
77750 12046 NCCI
77750 12047 NCCI
77750 12051 NCCI
77750 12052 NCCI
77750 12053 NCCI
77750 12054 NCCI
77750 12055 NCCI
77750 12056 NCCI
77750 12057 NCCI
77750 13100 NCCI
77750 13101 NCCI
77750 13102 NCCI
77750 13120 NCCI
77750 13121 NCCI
77750 13122 NCCI
77750 13131 NCCI
77750 13132 NCCI
77750 13133 NCCI
77750 13150 NCCI
77750 13151 NCCI
77750 13152 NCCI
77750 13153 NCCI
77750 16000 NCCI
77750 16020 NCCI
77750 16025 NCCI
77750 16030 NCCI
77750 36000 NCCI
77750 36400 NCCI
77750 36405 NCCI
77750 36406 NCCI
77750 36410 NCCI
77750 36420 NCCI
77750 36425 NCCI
77750 36430 NCCI
77750 36440 NCCI
77750 36600 NCCI
77750 36640 NCCI
77750 37202 NCCI
77750 43752 NCCI
77750 51701 NCCI
77750 51702 NCCI
77750 51703 NCCI
77750 62310 NCCI
77750 62311 NCCI
Comprehensive ComponentCode Code Source
77750 62318 NCCI
77750 62319 NCCI
77750 64400 NCCI
77750 64402 NCCI
77750 64405 NCCI
77750 64408 NCCI
77750 64410 NCCI
77750 64412 NCCI
77750 64413 NCCI
77750 64415 NCCI
77750 64416 NCCI
77750 64417 NCCI
77750 64418 NCCI
77750 64420 NCCI
77750 64421 NCCI
77750 64425 NCCI
77750 64430 NCCI
77750 64435 NCCI
77750 64445 NCCI
77750 64446 NCCI
77750 64447 NCCI
77750 64448 NCCI
77750 64449 NCCI
77750 64450 NCCI
77750 64479 NCCI
77750 64483 NCCI
77750 64490 NCCI
77750 64493 NCCI
77750 64505 NCCI
77750 64508 NCCI
77750 64510 NCCI
77750 64517 NCCI
77750 64520 NCCI
77750 64530 NCCI
77750 76000 NCCI
77750 76001 NCCI
77750 76873 NCCI
77750 76942 NCCI
77750 76998 NCCI
77750 77001 NCCI
77750 77002 NCCI
77750 77336 NCCI
77750 77427 NCCI
77750 77431 NCCI
77750 77785 NCCI
77750 77786 NCCI
77750 77787 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 150 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77750 78012 NCCI
77750 78013 NCCI
77750 78014 NCCI
77750 78072 NCCI
77750 78226 NCCI
77750 78227 NCCI
77750 78579 NCCI
77750 78582 NCCI
77750 78597 NCCI
77750 78598 NCCI
77750 79101 NCCI
77750 79101 NCCI
77750 79403 NCCI
77750 79440 NCCI
77750 79445 NCCI
77750 90832 NCCI
77750 90833 NCCI
77750 90834 NCCI
77750 90836 NCCI
77750 90837 NCCI
77750 90838 NCCI
77750 90839 NCCI
77750 90846 NCCI
77750 90847 NCCI
77750 93000 NCCI
77750 93005 NCCI
77750 93010 NCCI
77750 93040 NCCI
77750 93041 NCCI
77750 93042 NCCI
77750 93318 NCCI
77750 94002 NCCI
77750 94200 NCCI
77750 94250 NCCI
77750 94680 NCCI
77750 94681 NCCI
77750 94690 NCCI
77750 94770 NCCI
77750 95812 NCCI
77750 95813 NCCI
77750 95816 NCCI
77750 95819 NCCI
77750 95822 NCCI
77750 95829 NCCI
77750 95955 NCCI
77750 96360 NCCI
77750 96361 NCCI
Comprehensive ComponentCode Code Source
77750 96365 NCCI
77750 96366 NCCI
77750 96367 NCCI
77750 96368 NCCI
77750 96369 NCCI
77750 96372 NCCI
77750 96373 NCCI
77750 96374 NCCI
77750 96375 NCCI
77750 96376 NCCI
77750 96409 NCCI
77750 96413 NCCI
77750 96416 NCCI
77750 96420 NCCI
77750 96422 NCCI
77750 96425 NCCI
77750 97802 NCCI
77750 97803 NCCI
77750 97804 NCCI
77750 99143 NCCI
77750 99144 NCCI
77750 99145 NCCI
77750 99148 NCCI
77750 99149 NCCI
77750 99150 NCCI
77750 99201 NCCI
77750 99202 NCCI
77750 99203 NCCI
77750 99204 NCCI
77750 99205 NCCI
77750 99211 NCCI
77750 99212 NCCI
77750 99213 NCCI
77750 99214 NCCI
77750 99215 NCCI
77750 99217 NCCI
77750 99218 NCCI
77750 99219 NCCI
77750 99220 NCCI
77750 99221 NCCI
77750 99222 NCCI
77750 99223 NCCI
77750 99224 NCCI
77750 99225 NCCI
77750 99226 NCCI
77750 99231 NCCI
77750 99232 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 151 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77750 99233 NCCI
77750 99234 NCCI
77750 99235 NCCI
77750 99236 NCCI
77750 99238 NCCI
77750 99239 NCCI
77750 99241 NCCI
77750 99241 NCCI
77750 99242 NCCI
77750 99245 NCCI
77750 99245 NCCI
77750 99251 NCCI
77750 99251 NCCI
77750 99252 NCCI
77750 99253 NCCI
77750 99254 NCCI
77750 99255 NCCI
77750 99255 NCCI
77750 99281 NCCI
77750 99282 NCCI
77750 99283 NCCI
77750 99284 NCCI
77750 99285 NCCI
77750 99291 NCCI
77750 99292 NCCI
77750 99304 NCCI
77750 99305 NCCI
77750 99306 NCCI
77750 99307 NCCI
77750 99308 NCCI
77750 99309 NCCI
77750 99310 NCCI
77750 99315 NCCI
77750 99316 NCCI
77750 99318 NCCI
77750 99324 NCCI
77750 99325 NCCI
77750 99326 NCCI
77750 99327 NCCI
77750 99328 NCCI
77750 99334 NCCI
77750 99335 NCCI
77750 99336 NCCI
77750 99337 NCCI
77750 99341 NCCI
77750 99342 NCCI
77750 99343 NCCI
Comprehensive ComponentCode Code Source
77750 99344 NCCI
77750 99345 NCCI
77750 99347 NCCI
77750 99348 NCCI
77750 99349 NCCI
77750 99350 NCCI
77750 99354 NCCI
77750 99355 NCCI
77750 99356 NCCI
77750 99357 NCCI
77750 99360 NCCI
77750 99374 NCCI
77750 99375 NCCI
77750 99377 NCCI
77750 99378 NCCI
77750 99455 NCCI
77750 99456 NCCI
77750 99460 NCCI
77750 99461 NCCI
77750 99462 NCCI
77750 99463 NCCI
77750 99464 NCCI
77750 99465 NCCI
77750 99466 NCCI
77750 99467 NCCI
77750 99468 NCCI
77750 99469 NCCI
77750 99471 NCCI
77750 99472 NCCI
77750 99475 NCCI
77750 99476 NCCI
77750 99477 NCCI
77750 99478 NCCI
77750 99479 NCCI
77750 99480 NCCI
77750 99485 NCCI
77750 G0459 NCCI
77750 J1642 NCCI
77750 J1644 NCCI
77750 M0064 NCCI
77761 0182T NCCI
77761 0213T NCCI
77761 0216T NCCI
77761 0228T NCCI
77761 0230T NCCI
77761 11920 NCCI
77761 11921 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 152 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77761 12001 NCCI
77761 12002 NCCI
77761 12004 NCCI
77761 12005 NCCI
77761 12006 NCCI
77761 12007 NCCI
77761 12011 NCCI
77761 12013 NCCI
77761 12014 NCCI
77761 12015 NCCI
77761 12016 NCCI
77761 12017 NCCI
77761 12018 NCCI
77761 12020 NCCI
77761 12021 NCCI
77761 12031 NCCI
77761 12032 NCCI
77761 12034 NCCI
77761 12035 NCCI
77761 12036 NCCI
77761 12037 NCCI
77761 12041 NCCI
77761 12042 NCCI
77761 12044 NCCI
77761 12045 NCCI
77761 12046 NCCI
77761 12047 NCCI
77761 12051 NCCI
77761 12052 NCCI
77761 12053 NCCI
77761 12054 NCCI
77761 12055 NCCI
77761 12056 NCCI
77761 12057 NCCI
77761 13100 NCCI
77761 13101 NCCI
77761 13102 NCCI
77761 13120 NCCI
77761 13121 NCCI
77761 13122 NCCI
77761 13131 NCCI
77761 13132 NCCI
77761 13133 NCCI
77761 13150 NCCI
77761 13151 NCCI
77761 13152 NCCI
77761 13153 NCCI
Comprehensive ComponentCode Code Source
77761 16000 NCCI
77761 16020 NCCI
77761 16025 NCCI
77761 16030 NCCI
77761 36000 NCCI
77761 36400 NCCI
77761 36405 NCCI
77761 36406 NCCI
77761 36410 NCCI
77761 36420 NCCI
77761 36425 NCCI
77761 36430 NCCI
77761 36440 NCCI
77761 36600 NCCI
77761 36640 NCCI
77761 37202 NCCI
77761 43752 NCCI
77761 51701 NCCI
77761 51702 NCCI
77761 51703 NCCI
77761 62310 NCCI
77761 62311 NCCI
77761 62318 NCCI
77761 62319 NCCI
77761 64400 NCCI
77761 64402 NCCI
77761 64405 NCCI
77761 64408 NCCI
77761 64410 NCCI
77761 64412 NCCI
77761 64413 NCCI
77761 64415 NCCI
77761 64416 NCCI
77761 64417 NCCI
77761 64418 NCCI
77761 64420 NCCI
77761 64421 NCCI
77761 64425 NCCI
77761 64430 NCCI
77761 64435 NCCI
77761 64445 NCCI
77761 64446 NCCI
77761 64447 NCCI
77761 64448 NCCI
77761 64449 NCCI
77761 64450 NCCI
77761 64479 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 153 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77761 64483 NCCI
77761 64490 NCCI
77761 64493 NCCI
77761 64505 NCCI
77761 64508 NCCI
77761 64510 NCCI
77761 64517 NCCI
77761 64520 NCCI
77761 64530 NCCI
77761 76873 NCCI
77761 77336 NCCI
77761 77427 NCCI
77761 77431 NCCI
77761 77785 NCCI
77761 77786 NCCI
77761 77787 NCCI
77761 78012 NCCI
77761 78013 NCCI
77761 78014 NCCI
77761 78071 NCCI
77761 78072 NCCI
77761 78226 NCCI
77761 78227 NCCI
77761 78579 NCCI
77761 78582 NCCI
77761 78597 NCCI
77761 78598 NCCI
77761 79200 NCCI
77761 79440 NCCI
77761 90832 NCCI
77761 90833 NCCI
77761 90834 NCCI
77761 90836 NCCI
77761 90837 NCCI
77761 90838 NCCI
77761 90839 NCCI
77761 90846 NCCI
77761 90847 NCCI
77761 93000 NCCI
77761 93005 NCCI
77761 93010 NCCI
77761 93040 NCCI
77761 93041 NCCI
77761 93042 NCCI
77761 93318 NCCI
77761 94002 NCCI
77761 94200 NCCI
Comprehensive ComponentCode Code Source
77761 94250 NCCI
77761 94680 NCCI
77761 94681 NCCI
77761 94690 NCCI
77761 94770 NCCI
77761 95812 NCCI
77761 95813 NCCI
77761 95816 NCCI
77761 95819 NCCI
77761 95822 NCCI
77761 95829 NCCI
77761 95955 NCCI
77761 96360 NCCI
77761 96361 NCCI
77761 96365 NCCI
77761 96366 NCCI
77761 96367 NCCI
77761 96368 NCCI
77761 96372 NCCI
77761 96374 NCCI
77761 96375 NCCI
77761 96376 NCCI
77761 97802 NCCI
77761 97803 NCCI
77761 97804 NCCI
77761 99143 NCCI
77761 99144 NCCI
77761 99145 NCCI
77761 99148 NCCI
77761 99149 NCCI
77761 99150 NCCI
77761 99201 NCCI
77761 99202 NCCI
77761 99203 NCCI
77761 99204 NCCI
77761 99205 NCCI
77761 99211 NCCI
77761 99212 NCCI
77761 99213 NCCI
77761 99214 NCCI
77761 99215 NCCI
77761 99217 NCCI
77761 99218 NCCI
77761 99219 NCCI
77761 99220 NCCI
77761 99221 NCCI
77761 99222 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 154 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77761 99223 NCCI
77761 99224 NCCI
77761 99225 NCCI
77761 99226 NCCI
77761 99231 NCCI
77761 99232 NCCI
77761 99233 NCCI
77761 99234 NCCI
77761 99235 NCCI
77761 99236 NCCI
77761 99238 NCCI
77761 99239 NCCI
77761 99241 NCCI
77761 99242 NCCI
77761 99243 NCCI
77761 99245 NCCI
77761 99251 NCCI
77761 99252 NCCI
77761 99253 NCCI
77761 99254 NCCI
77761 99255 NCCI
77761 99255 NCCI
77761 99281 NCCI
77761 99282 NCCI
77761 99283 NCCI
77761 99284 NCCI
77761 99285 NCCI
77761 99291 NCCI
77761 99292 NCCI
77761 99304 NCCI
77761 99305 NCCI
77761 99306 NCCI
77761 99307 NCCI
77761 99308 NCCI
77761 99309 NCCI
77761 99310 NCCI
77761 99315 NCCI
77761 99316 NCCI
77761 99318 NCCI
77761 99324 NCCI
77761 99325 NCCI
77761 99326 NCCI
77761 99327 NCCI
77761 99328 NCCI
77761 99334 NCCI
77761 99335 NCCI
77761 99336 NCCI
Comprehensive ComponentCode Code Source
77761 99337 NCCI
77761 99341 NCCI
77761 99342 NCCI
77761 99343 NCCI
77761 99344 NCCI
77761 99345 NCCI
77761 99347 NCCI
77761 99348 NCCI
77761 99349 NCCI
77761 99350 NCCI
77761 99354 NCCI
77761 99355 NCCI
77761 99356 NCCI
77761 99357 NCCI
77761 99360 NCCI
77761 99374 NCCI
77761 99375 NCCI
77761 99377 NCCI
77761 99378 NCCI
77761 99455 NCCI
77761 99456 NCCI
77761 99460 NCCI
77761 99461 NCCI
77761 99462 NCCI
77761 99463 NCCI
77761 99464 NCCI
77761 99465 NCCI
77761 99466 NCCI
77761 99467 NCCI
77761 99468 NCCI
77761 99469 NCCI
77761 99471 NCCI
77761 99472 NCCI
77761 99475 NCCI
77761 99476 NCCI
77761 99477 NCCI
77761 99478 NCCI
77761 99479 NCCI
77761 99480 NCCI
77761 99485 NCCI
77761 G0459 NCCI
77761 M0064 NCCI
77762 0182T NCCI
77762 0213T NCCI
77762 0216T NCCI
77762 0228T NCCI
77762 0230T NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 155 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77762 11920 NCCI
77762 11921 NCCI
77762 12001 NCCI
77762 12002 NCCI
77762 12004 NCCI
77762 12005 NCCI
77762 12006 NCCI
77762 12007 NCCI
77762 12011 NCCI
77762 12013 NCCI
77762 12014 NCCI
77762 12015 NCCI
77762 12016 NCCI
77762 12017 NCCI
77762 12018 NCCI
77762 12020 NCCI
77762 12021 NCCI
77762 12031 NCCI
77762 12032 NCCI
77762 12034 NCCI
77762 12035 NCCI
77762 12036 NCCI
77762 12037 NCCI
77762 12041 NCCI
77762 12042 NCCI
77762 12044 NCCI
77762 12045 NCCI
77762 12046 NCCI
77762 12047 NCCI
77762 12051 NCCI
77762 12052 NCCI
77762 12053 NCCI
77762 12054 NCCI
77762 12055 NCCI
77762 12056 NCCI
77762 12057 NCCI
77762 13100 NCCI
77762 13101 NCCI
77762 13102 NCCI
77762 13120 NCCI
77762 13121 NCCI
77762 13122 NCCI
77762 13131 NCCI
77762 13132 NCCI
77762 13133 NCCI
77762 13150 NCCI
77762 13151 NCCI
Comprehensive ComponentCode Code Source
77762 13152 NCCI
77762 13153 NCCI
77762 16000 NCCI
77762 16020 NCCI
77762 16025 NCCI
77762 16030 NCCI
77762 36000 NCCI
77762 36400 NCCI
77762 36405 NCCI
77762 36406 NCCI
77762 36410 NCCI
77762 36420 NCCI
77762 36425 NCCI
77762 36430 NCCI
77762 36440 NCCI
77762 36600 NCCI
77762 36640 NCCI
77762 37202 NCCI
77762 43752 NCCI
77762 51701 NCCI
77762 51702 NCCI
77762 51703 NCCI
77762 62310 NCCI
77762 62311 NCCI
77762 62318 NCCI
77762 62319 NCCI
77762 64400 NCCI
77762 64402 NCCI
77762 64405 NCCI
77762 64408 NCCI
77762 64410 NCCI
77762 64412 NCCI
77762 64413 NCCI
77762 64415 NCCI
77762 64416 NCCI
77762 64417 NCCI
77762 64418 NCCI
77762 64420 NCCI
77762 64421 NCCI
77762 64425 NCCI
77762 64430 NCCI
77762 64435 NCCI
77762 64445 NCCI
77762 64446 NCCI
77762 64447 NCCI
77762 64448 NCCI
77762 64449 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 156 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77762 64450 NCCI
77762 64479 NCCI
77762 64483 NCCI
77762 64490 NCCI
77762 64493 NCCI
77762 64505 NCCI
77762 64508 NCCI
77762 64510 NCCI
77762 64517 NCCI
77762 64520 NCCI
77762 64530 NCCI
77762 76873 NCCI
77762 77336 NCCI
77762 77427 NCCI
77762 77431 NCCI
77762 77761 NCCI
77762 77785 NCCI
77762 77786 NCCI
77762 77787 NCCI
77762 78012 NCCI
77762 78013 NCCI
77762 78014 NCCI
77762 78071 NCCI
77762 78072 NCCI
77762 78226 NCCI
77762 78227 NCCI
77762 78579 NCCI
77762 78582 NCCI
77762 78597 NCCI
77762 78598 NCCI
77762 79200 NCCI
77762 79440 NCCI
77762 90832 NCCI
77762 90833 NCCI
77762 90834 NCCI
77762 90836 NCCI
77762 90837 NCCI
77762 90838 NCCI
77762 90839 NCCI
77762 90846 NCCI
77762 90847 NCCI
77762 93000 NCCI
77762 93005 NCCI
77762 93010 NCCI
77762 93040 NCCI
77762 93041 NCCI
77762 93042 NCCI
Comprehensive ComponentCode Code Source
77762 93318 NCCI
77762 94002 NCCI
77762 94200 NCCI
77762 94250 NCCI
77762 94680 NCCI
77762 94681 NCCI
77762 94690 NCCI
77762 94770 NCCI
77762 95812 NCCI
77762 95813 NCCI
77762 95816 NCCI
77762 95819 NCCI
77762 95822 NCCI
77762 95829 NCCI
77762 95955 NCCI
77762 96360 NCCI
77762 96361 NCCI
77762 96365 NCCI
77762 96366 NCCI
77762 96367 NCCI
77762 96368 NCCI
77762 96372 NCCI
77762 96374 NCCI
77762 96375 NCCI
77762 96376 NCCI
77762 97802 NCCI
77762 97803 NCCI
77762 97804 NCCI
77762 99143 NCCI
77762 99144 NCCI
77762 99145 NCCI
77762 99148 NCCI
77762 99149 NCCI
77762 99150 NCCI
77762 99201 NCCI
77762 99202 NCCI
77762 99203 NCCI
77762 99204 NCCI
77762 99205 NCCI
77762 99211 NCCI
77762 99212 NCCI
77762 99213 NCCI
77762 99214 NCCI
77762 99215 NCCI
77762 99217 NCCI
77762 99218 NCCI
77762 99219 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 157 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77762 99220 NCCI
77762 99221 NCCI
77762 99222 NCCI
77762 99223 NCCI
77762 99224 NCCI
77762 99225 NCCI
77762 99226 NCCI
77762 99231 NCCI
77762 99232 NCCI
77762 99233 NCCI
77762 99234 NCCI
77762 99235 NCCI
77762 99236 NCCI
77762 99238 NCCI
77762 99239 NCCI
77762 99241 NCCI
77762 99242 NCCI
77762 99243 NCCI
77762 99245 NCCI
77762 99253 NCCI
77762 99254 NCCI
77762 99255 NCCI
77762 99281 NCCI
77762 99282 NCCI
77762 99283 NCCI
77762 99284 NCCI
77762 99285 NCCI
77762 99291 NCCI
77762 99292 NCCI
77762 99304 NCCI
77762 99305 NCCI
77762 99306 NCCI
77762 99307 NCCI
77762 99308 NCCI
77762 99309 NCCI
77762 99310 NCCI
77762 99315 NCCI
77762 99316 NCCI
77762 99318 NCCI
77762 99324 NCCI
77762 99325 NCCI
77762 99326 NCCI
77762 99327 NCCI
77762 99328 NCCI
77762 99334 NCCI
77762 99335 NCCI
77762 99336 NCCI
Comprehensive ComponentCode Code Source
77762 99337 NCCI
77762 99341 NCCI
77762 99342 NCCI
77762 99343 NCCI
77762 99344 NCCI
77762 99345 NCCI
77762 99347 NCCI
77762 99348 NCCI
77762 99349 NCCI
77762 99350 NCCI
77762 99354 NCCI
77762 99355 NCCI
77762 99356 NCCI
77762 99357 NCCI
77762 99360 NCCI
77762 99374 NCCI
77762 99375 NCCI
77762 99377 NCCI
77762 99378 NCCI
77762 99455 NCCI
77762 99456 NCCI
77762 99460 NCCI
77762 99461 NCCI
77762 99462 NCCI
77762 99463 NCCI
77762 99464 NCCI
77762 99465 NCCI
77762 99466 NCCI
77762 99467 NCCI
77762 99468 NCCI
77762 99469 NCCI
77762 99471 NCCI
77762 99472 NCCI
77762 99475 NCCI
77762 99476 NCCI
77762 99477 NCCI
77762 99478 NCCI
77762 99479 NCCI
77762 99480 NCCI
77762 99485 NCCI
77762 G0459 NCCI
77762 M0064 NCCI
77763 0182T NCCI
77763 0213T NCCI
77763 0216T NCCI
77763 0228T NCCI
77763 0230T NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 158 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77763 11920 NCCI
77763 11921 NCCI
77763 12001 NCCI
77763 12002 NCCI
77763 12004 NCCI
77763 12005 NCCI
77763 12006 NCCI
77763 12007 NCCI
77763 12011 NCCI
77763 12013 NCCI
77763 12014 NCCI
77763 12015 NCCI
77763 12016 NCCI
77763 12017 NCCI
77763 12018 NCCI
77763 12020 NCCI
77763 12021 NCCI
77763 12031 NCCI
77763 12032 NCCI
77763 12034 NCCI
77763 12035 NCCI
77763 12036 NCCI
77763 12037 NCCI
77763 12041 NCCI
77763 12042 NCCI
77763 12044 NCCI
77763 12045 NCCI
77763 12046 NCCI
77763 12047 NCCI
77763 12051 NCCI
77763 12052 NCCI
77763 12053 NCCI
77763 12054 NCCI
77763 12055 NCCI
77763 12056 NCCI
77763 12057 NCCI
77763 13100 NCCI
77763 13101 NCCI
77763 13102 NCCI
77763 13120 NCCI
77763 13121 NCCI
77763 13122 NCCI
77763 13131 NCCI
77763 13132 NCCI
77763 13133 NCCI
77763 13150 NCCI
77763 13151 NCCI
Comprehensive ComponentCode Code Source
77763 13152 NCCI
77763 13153 NCCI
77763 16000 NCCI
77763 16020 NCCI
77763 16025 NCCI
77763 16030 NCCI
77763 36000 NCCI
77763 36400 NCCI
77763 36405 NCCI
77763 36406 NCCI
77763 36410 NCCI
77763 36420 NCCI
77763 36425 NCCI
77763 36430 NCCI
77763 36440 NCCI
77763 36600 NCCI
77763 36640 NCCI
77763 37202 NCCI
77763 43752 NCCI
77763 51701 NCCI
77763 51702 NCCI
77763 51703 NCCI
77763 62310 NCCI
77763 62311 NCCI
77763 62318 NCCI
77763 62319 NCCI
77763 64400 NCCI
77763 64402 NCCI
77763 64405 NCCI
77763 64408 NCCI
77763 64410 NCCI
77763 64412 NCCI
77763 64413 NCCI
77763 64415 NCCI
77763 64416 NCCI
77763 64417 NCCI
77763 64418 NCCI
77763 64420 NCCI
77763 64421 NCCI
77763 64425 NCCI
77763 64430 NCCI
77763 64435 NCCI
77763 64445 NCCI
77763 64446 NCCI
77763 64447 NCCI
77763 64448 NCCI
77763 64449 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 159 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77763 64450 NCCI
77763 64479 NCCI
77763 64483 NCCI
77763 64490 NCCI
77763 64493 NCCI
77763 64505 NCCI
77763 64508 NCCI
77763 64510 NCCI
77763 64517 NCCI
77763 64520 NCCI
77763 64530 NCCI
77763 76873 NCCI
77763 77336 NCCI
77763 77427 NCCI
77763 77431 NCCI
77763 77761 NCCI
77763 77762 NCCI
77763 77785 NCCI
77763 77786 NCCI
77763 77787 NCCI
77763 78012 NCCI
77763 78013 NCCI
77763 78014 NCCI
77763 78071 NCCI
77763 78072 NCCI
77763 78226 NCCI
77763 78227 NCCI
77763 78579 NCCI
77763 78582 NCCI
77763 78597 NCCI
77763 78598 NCCI
77763 79200 NCCI
77763 79440 NCCI
77763 90832 NCCI
77763 90833 NCCI
77763 90834 NCCI
77763 90836 NCCI
77763 90837 NCCI
77763 90838 NCCI
77763 90839 NCCI
77763 90846 NCCI
77763 90847 NCCI
77763 93000 NCCI
77763 93005 NCCI
77763 93010 NCCI
77763 93040 NCCI
77763 93041 NCCI
Comprehensive ComponentCode Code Source
77763 93042 NCCI
77763 93318 NCCI
77763 94002 NCCI
77763 94200 NCCI
77763 94250 NCCI
77763 94680 NCCI
77763 94681 NCCI
77763 94690 NCCI
77763 94770 NCCI
77763 95812 NCCI
77763 95813 NCCI
77763 95816 NCCI
77763 95819 NCCI
77763 95822 NCCI
77763 95829 NCCI
77763 95955 NCCI
77763 96360 NCCI
77763 96361 NCCI
77763 96365 NCCI
77763 96366 NCCI
77763 96367 NCCI
77763 96368 NCCI
77763 96372 NCCI
77763 96374 NCCI
77763 96375 NCCI
77763 96376 NCCI
77763 97802 NCCI
77763 97803 NCCI
77763 97804 NCCI
77763 99143 NCCI
77763 99144 NCCI
77763 99145 NCCI
77763 99148 NCCI
77763 99149 NCCI
77763 99150 NCCI
77763 99201 NCCI
77763 99202 NCCI
77763 99203 NCCI
77763 99204 NCCI
77763 99205 NCCI
77763 99211 NCCI
77763 99212 NCCI
77763 99213 NCCI
77763 99214 NCCI
77763 99215 NCCI
77763 99217 NCCI
77763 99218 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 160 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77763 99219 NCCI
77763 99220 NCCI
77763 99221 NCCI
77763 99222 NCCI
77763 99223 NCCI
77763 99224 NCCI
77763 99225 NCCI
77763 99226 NCCI
77763 99231 NCCI
77763 99232 NCCI
77763 99233 NCCI
77763 99234 NCCI
77763 99235 NCCI
77763 99236 NCCI
77763 99238 NCCI
77763 99239 NCCI
77763 99242 NCCI
77763 99243 NCCI
77763 99244 NCCI
77763 99245 NCCI
77763 99251 NCCI
77763 99252 NCCI
77763 99253 NCCI
77763 99255 NCCI
77763 99255 NCCI
77763 99281 NCCI
77763 99282 NCCI
77763 99283 NCCI
77763 99284 NCCI
77763 99285 NCCI
77763 99291 NCCI
77763 99292 NCCI
77763 99304 NCCI
77763 99305 NCCI
77763 99306 NCCI
77763 99307 NCCI
77763 99308 NCCI
77763 99309 NCCI
77763 99310 NCCI
77763 99315 NCCI
77763 99316 NCCI
77763 99318 NCCI
77763 99324 NCCI
77763 99325 NCCI
77763 99326 NCCI
77763 99327 NCCI
77763 99328 NCCI
Comprehensive ComponentCode Code Source
77763 99334 NCCI
77763 99335 NCCI
77763 99336 NCCI
77763 99337 NCCI
77763 99341 NCCI
77763 99342 NCCI
77763 99343 NCCI
77763 99344 NCCI
77763 99345 NCCI
77763 99347 NCCI
77763 99348 NCCI
77763 99349 NCCI
77763 99350 NCCI
77763 99354 NCCI
77763 99355 NCCI
77763 99356 NCCI
77763 99357 NCCI
77763 99360 NCCI
77763 99374 NCCI
77763 99375 NCCI
77763 99377 NCCI
77763 99378 NCCI
77763 99455 NCCI
77763 99456 NCCI
77763 99460 NCCI
77763 99461 NCCI
77763 99462 NCCI
77763 99463 NCCI
77763 99464 NCCI
77763 99465 NCCI
77763 99466 NCCI
77763 99467 NCCI
77763 99468 NCCI
77763 99469 NCCI
77763 99471 NCCI
77763 99472 NCCI
77763 99475 NCCI
77763 99476 NCCI
77763 99477 NCCI
77763 99478 NCCI
77763 99479 NCCI
77763 99480 NCCI
77763 99485 NCCI
77763 G0459 NCCI
77763 M0064 NCCI
77776 0182T NCCI
77776 0213T NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 161 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77776 0216T NCCI
77776 0228T NCCI
77776 0230T NCCI
77776 11920 NCCI
77776 11921 NCCI
77776 12001 NCCI
77776 12002 NCCI
77776 12004 NCCI
77776 12005 NCCI
77776 12006 NCCI
77776 12007 NCCI
77776 12011 NCCI
77776 12013 NCCI
77776 12014 NCCI
77776 12015 NCCI
77776 12016 NCCI
77776 12017 NCCI
77776 12018 NCCI
77776 12020 NCCI
77776 12021 NCCI
77776 12031 NCCI
77776 12032 NCCI
77776 12034 NCCI
77776 12035 NCCI
77776 12036 NCCI
77776 12037 NCCI
77776 12041 NCCI
77776 12042 NCCI
77776 12044 NCCI
77776 12045 NCCI
77776 12046 NCCI
77776 12047 NCCI
77776 12051 NCCI
77776 12052 NCCI
77776 12053 NCCI
77776 12054 NCCI
77776 12055 NCCI
77776 12056 NCCI
77776 12057 NCCI
77776 13100 NCCI
77776 13101 NCCI
77776 13102 NCCI
77776 13120 NCCI
77776 13121 NCCI
77776 13122 NCCI
77776 13131 NCCI
77776 13132 NCCI
Comprehensive ComponentCode Code Source
77776 13133 NCCI
77776 13150 NCCI
77776 13151 NCCI
77776 13152 NCCI
77776 13153 NCCI
77776 16000 NCCI
77776 16020 NCCI
77776 16025 NCCI
77776 16030 NCCI
77776 36000 NCCI
77776 36400 NCCI
77776 36405 NCCI
77776 36406 NCCI
77776 36410 NCCI
77776 36420 NCCI
77776 36425 NCCI
77776 36430 NCCI
77776 36440 NCCI
77776 36600 NCCI
77776 36640 NCCI
77776 37202 NCCI
77776 43752 NCCI
77776 51701 NCCI
77776 51702 NCCI
77776 51703 NCCI
77776 62310 NCCI
77776 62311 NCCI
77776 62318 NCCI
77776 62319 NCCI
77776 64400 NCCI
77776 64402 NCCI
77776 64405 NCCI
77776 64408 NCCI
77776 64410 NCCI
77776 64412 NCCI
77776 64413 NCCI
77776 64415 NCCI
77776 64416 NCCI
77776 64417 NCCI
77776 64418 NCCI
77776 64420 NCCI
77776 64421 NCCI
77776 64425 NCCI
77776 64430 NCCI
77776 64435 NCCI
77776 64445 NCCI
77776 64446 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 162 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77776 64447 NCCI
77776 64448 NCCI
77776 64449 NCCI
77776 64450 NCCI
77776 64479 NCCI
77776 64483 NCCI
77776 64490 NCCI
77776 64493 NCCI
77776 64505 NCCI
77776 64508 NCCI
77776 64510 NCCI
77776 64517 NCCI
77776 64520 NCCI
77776 64530 NCCI
77776 76873 NCCI
77776 77336 NCCI
77776 77427 NCCI
77776 77431 NCCI
77776 77761 NCCI
77776 77762 NCCI
77776 77763 NCCI
77776 77785 NCCI
77776 77786 NCCI
77776 77787 NCCI
77776 78012 NCCI
77776 78013 NCCI
77776 78014 NCCI
77776 78071 NCCI
77776 78072 NCCI
77776 78226 NCCI
77776 78227 NCCI
77776 78579 NCCI
77776 78582 NCCI
77776 78597 NCCI
77776 78598 NCCI
77776 79300 NCCI
77776 79445 NCCI
77776 90832 NCCI
77776 90833 NCCI
77776 90834 NCCI
77776 90836 NCCI
77776 90837 NCCI
77776 90838 NCCI
77776 90839 NCCI
77776 90846 NCCI
77776 90847 NCCI
77776 93000 NCCI
Comprehensive ComponentCode Code Source
77776 93005 NCCI
77776 93010 NCCI
77776 93040 NCCI
77776 93041 NCCI
77776 93042 NCCI
77776 93318 NCCI
77776 94002 NCCI
77776 94200 NCCI
77776 94250 NCCI
77776 94680 NCCI
77776 94681 NCCI
77776 94690 NCCI
77776 94770 NCCI
77776 95812 NCCI
77776 95813 NCCI
77776 95816 NCCI
77776 95819 NCCI
77776 95822 NCCI
77776 95829 NCCI
77776 95955 NCCI
77776 96360 NCCI
77776 96361 NCCI
77776 96365 NCCI
77776 96366 NCCI
77776 96367 NCCI
77776 96368 NCCI
77776 96372 NCCI
77776 96374 NCCI
77776 96375 NCCI
77776 96376 NCCI
77776 97802 NCCI
77776 97803 NCCI
77776 97804 NCCI
77776 99143 NCCI
77776 99144 NCCI
77776 99145 NCCI
77776 99148 NCCI
77776 99149 NCCI
77776 99150 NCCI
77776 99201 NCCI
77776 99202 NCCI
77776 99203 NCCI
77776 99204 NCCI
77776 99205 NCCI
77776 99211 NCCI
77776 99212 NCCI
77776 99213 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 163 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77776 99214 NCCI
77776 99215 NCCI
77776 99217 NCCI
77776 99218 NCCI
77776 99219 NCCI
77776 99220 NCCI
77776 99221 NCCI
77776 99222 NCCI
77776 99223 NCCI
77776 99224 NCCI
77776 99225 NCCI
77776 99226 NCCI
77776 99231 NCCI
77776 99232 NCCI
77776 99233 NCCI
77776 99234 NCCI
77776 99235 NCCI
77776 99236 NCCI
77776 99238 NCCI
77776 99239 NCCI
77776 99241 NCCI
77776 99241 NCCI
77776 99242 NCCI
77776 99243 NCCI
77776 99243 NCCI
77776 99245 NCCI
77776 99251 NCCI
77776 99252 NCCI
77776 99253 NCCI
77776 99255 NCCI
77776 99281 NCCI
77776 99282 NCCI
77776 99283 NCCI
77776 99284 NCCI
77776 99285 NCCI
77776 99291 NCCI
77776 99292 NCCI
77776 99304 NCCI
77776 99305 NCCI
77776 99306 NCCI
77776 99307 NCCI
77776 99308 NCCI
77776 99309 NCCI
77776 99310 NCCI
77776 99315 NCCI
77776 99316 NCCI
77776 99318 NCCI
Comprehensive ComponentCode Code Source
77776 99324 NCCI
77776 99325 NCCI
77776 99326 NCCI
77776 99327 NCCI
77776 99328 NCCI
77776 99334 NCCI
77776 99335 NCCI
77776 99336 NCCI
77776 99337 NCCI
77776 99341 NCCI
77776 99342 NCCI
77776 99343 NCCI
77776 99344 NCCI
77776 99345 NCCI
77776 99347 NCCI
77776 99348 NCCI
77776 99349 NCCI
77776 99350 NCCI
77776 99354 NCCI
77776 99356 NCCI
77776 99357 NCCI
77776 99374 NCCI
77776 99375 NCCI
77776 99377 NCCI
77776 99378 NCCI
77776 99455 NCCI
77776 99456 NCCI
77776 99460 NCCI
77776 99461 NCCI
77776 99462 NCCI
77776 99463 NCCI
77776 99464 NCCI
77776 99465 NCCI
77776 99466 NCCI
77776 99467 NCCI
77776 99468 NCCI
77776 99469 NCCI
77776 99471 NCCI
77776 99472 NCCI
77776 99475 NCCI
77776 99476 NCCI
77776 99477 NCCI
77776 99478 NCCI
77776 99479 NCCI
77776 99480 NCCI
77776 99485 NCCI
77776 G0459 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 164 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77776 M0064 NCCI
77777 0182T NCCI
77777 0213T NCCI
77777 0216T NCCI
77777 0228T NCCI
77777 0230T NCCI
77777 11920 NCCI
77777 11921 NCCI
77777 12001 NCCI
77777 12002 NCCI
77777 12004 NCCI
77777 12005 NCCI
77777 12006 NCCI
77777 12007 NCCI
77777 12011 NCCI
77777 12013 NCCI
77777 12014 NCCI
77777 12015 NCCI
77777 12016 NCCI
77777 12017 NCCI
77777 12018 NCCI
77777 12020 NCCI
77777 12021 NCCI
77777 12031 NCCI
77777 12032 NCCI
77777 12034 NCCI
77777 12035 NCCI
77777 12036 NCCI
77777 12037 NCCI
77777 12041 NCCI
77777 12042 NCCI
77777 12044 NCCI
77777 12045 NCCI
77777 12046 NCCI
77777 12047 NCCI
77777 12051 NCCI
77777 12052 NCCI
77777 12053 NCCI
77777 12054 NCCI
77777 12055 NCCI
77777 12056 NCCI
77777 12057 NCCI
77777 13100 NCCI
77777 13101 NCCI
77777 13102 NCCI
77777 13120 NCCI
77777 13121 NCCI
Comprehensive ComponentCode Code Source
77777 13122 NCCI
77777 13131 NCCI
77777 13132 NCCI
77777 13133 NCCI
77777 13150 NCCI
77777 13151 NCCI
77777 13152 NCCI
77777 13153 NCCI
77777 16000 NCCI
77777 16020 NCCI
77777 16025 NCCI
77777 16030 NCCI
77777 36000 NCCI
77777 36400 NCCI
77777 36405 NCCI
77777 36406 NCCI
77777 36410 NCCI
77777 36420 NCCI
77777 36425 NCCI
77777 36430 NCCI
77777 36440 NCCI
77777 36600 NCCI
77777 36640 NCCI
77777 37202 NCCI
77777 43752 NCCI
77777 51701 NCCI
77777 51702 NCCI
77777 51703 NCCI
77777 62310 NCCI
77777 62311 NCCI
77777 62318 NCCI
77777 62319 NCCI
77777 64400 NCCI
77777 64402 NCCI
77777 64405 NCCI
77777 64408 NCCI
77777 64410 NCCI
77777 64412 NCCI
77777 64413 NCCI
77777 64415 NCCI
77777 64416 NCCI
77777 64417 NCCI
77777 64418 NCCI
77777 64420 NCCI
77777 64421 NCCI
77777 64425 NCCI
77777 64430 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 165 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77777 64435 NCCI
77777 64445 NCCI
77777 64446 NCCI
77777 64447 NCCI
77777 64448 NCCI
77777 64449 NCCI
77777 64450 NCCI
77777 64479 NCCI
77777 64483 NCCI
77777 64490 NCCI
77777 64493 NCCI
77777 64505 NCCI
77777 64508 NCCI
77777 64510 NCCI
77777 64517 NCCI
77777 64520 NCCI
77777 64530 NCCI
77777 76873 NCCI
77777 77336 NCCI
77777 77427 NCCI
77777 77431 NCCI
77777 77761 NCCI
77777 77762 NCCI
77777 77763 NCCI
77777 77776 NCCI
77777 77785 NCCI
77777 77786 NCCI
77777 77787 NCCI
77777 78012 NCCI
77777 78013 NCCI
77777 78014 NCCI
77777 78071 NCCI
77777 78072 NCCI
77777 78226 NCCI
77777 78227 NCCI
77777 78579 NCCI
77777 78582 NCCI
77777 78597 NCCI
77777 78598 NCCI
77777 79300 NCCI
77777 79445 NCCI
77777 90832 NCCI
77777 90833 NCCI
77777 90834 NCCI
77777 90836 NCCI
77777 90837 NCCI
77777 90838 NCCI
Comprehensive ComponentCode Code Source
77777 90839 NCCI
77777 90846 NCCI
77777 90847 NCCI
77777 93000 NCCI
77777 93005 NCCI
77777 93010 NCCI
77777 93040 NCCI
77777 93041 NCCI
77777 93042 NCCI
77777 93318 NCCI
77777 94002 NCCI
77777 94200 NCCI
77777 94250 NCCI
77777 94680 NCCI
77777 94681 NCCI
77777 94690 NCCI
77777 94770 NCCI
77777 95812 NCCI
77777 95813 NCCI
77777 95816 NCCI
77777 95819 NCCI
77777 95822 NCCI
77777 95829 NCCI
77777 95955 NCCI
77777 96360 NCCI
77777 96361 NCCI
77777 96365 NCCI
77777 96366 NCCI
77777 96367 NCCI
77777 96368 NCCI
77777 96372 NCCI
77777 96374 NCCI
77777 96375 NCCI
77777 96376 NCCI
77777 97802 NCCI
77777 97803 NCCI
77777 97804 NCCI
77777 99143 NCCI
77777 99144 NCCI
77777 99145 NCCI
77777 99148 NCCI
77777 99149 NCCI
77777 99150 NCCI
77777 99201 NCCI
77777 99202 NCCI
77777 99203 NCCI
77777 99204 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 166 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77777 99205 NCCI
77777 99211 NCCI
77777 99212 NCCI
77777 99213 NCCI
77777 99214 NCCI
77777 99215 NCCI
77777 99217 NCCI
77777 99218 NCCI
77777 99219 NCCI
77777 99220 NCCI
77777 99221 NCCI
77777 99222 NCCI
77777 99223 NCCI
77777 99224 NCCI
77777 99225 NCCI
77777 99226 NCCI
77777 99231 NCCI
77777 99232 NCCI
77777 99233 NCCI
77777 99234 NCCI
77777 99235 NCCI
77777 99236 NCCI
77777 99238 NCCI
77777 99239 NCCI
77777 99242 NCCI
77777 99243 NCCI
77777 99244 NCCI
77777 99245 NCCI
77777 99245 NCCI
77777 99251 NCCI
77777 99251 NCCI
77777 99252 NCCI
77777 99253 NCCI
77777 99255 NCCI
77777 99255 NCCI
77777 99281 NCCI
77777 99282 NCCI
77777 99283 NCCI
77777 99284 NCCI
77777 99285 NCCI
77777 99291 NCCI
77777 99292 NCCI
77777 99304 NCCI
77777 99305 NCCI
77777 99306 NCCI
77777 99307 NCCI
77777 99308 NCCI
Comprehensive ComponentCode Code Source
77777 99309 NCCI
77777 99310 NCCI
77777 99315 NCCI
77777 99316 NCCI
77777 99318 NCCI
77777 99324 NCCI
77777 99325 NCCI
77777 99326 NCCI
77777 99327 NCCI
77777 99328 NCCI
77777 99334 NCCI
77777 99335 NCCI
77777 99336 NCCI
77777 99337 NCCI
77777 99341 NCCI
77777 99342 NCCI
77777 99343 NCCI
77777 99344 NCCI
77777 99345 NCCI
77777 99347 NCCI
77777 99348 NCCI
77777 99349 NCCI
77777 99350 NCCI
77777 99354 NCCI
77777 99355 NCCI
77777 99356 NCCI
77777 99357 NCCI
77777 99360 NCCI
77777 99374 NCCI
77777 99375 NCCI
77777 99377 NCCI
77777 99378 NCCI
77777 99455 NCCI
77777 99456 NCCI
77777 99460 NCCI
77777 99461 NCCI
77777 99462 NCCI
77777 99463 NCCI
77777 99464 NCCI
77777 99465 NCCI
77777 99466 NCCI
77777 99467 NCCI
77777 99468 NCCI
77777 99469 NCCI
77777 99471 NCCI
77777 99472 NCCI
77777 99475 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 167 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77777 99476 NCCI
77777 99477 NCCI
77777 99478 NCCI
77777 99479 NCCI
77777 99480 NCCI
77777 99485 NCCI
77777 G0459 NCCI
77777 M0064 NCCI
77778 0182T NCCI
77778 0213T NCCI
77778 0216T NCCI
77778 0228T NCCI
77778 0230T NCCI
77778 11920 NCCI
77778 11921 NCCI
77778 12001 NCCI
77778 12002 NCCI
77778 12004 NCCI
77778 12005 NCCI
77778 12006 NCCI
77778 12007 NCCI
77778 12011 NCCI
77778 12013 NCCI
77778 12014 NCCI
77778 12015 NCCI
77778 12016 NCCI
77778 12017 NCCI
77778 12018 NCCI
77778 12020 NCCI
77778 12021 NCCI
77778 12031 NCCI
77778 12032 NCCI
77778 12034 NCCI
77778 12035 NCCI
77778 12036 NCCI
77778 12037 NCCI
77778 12041 NCCI
77778 12042 NCCI
77778 12044 NCCI
77778 12045 NCCI
77778 12046 NCCI
77778 12047 NCCI
77778 12051 NCCI
77778 12052 NCCI
77778 12053 NCCI
77778 12054 NCCI
77778 12055 NCCI
Comprehensive ComponentCode Code Source
77778 12056 NCCI
77778 12057 NCCI
77778 13100 NCCI
77778 13101 NCCI
77778 13102 NCCI
77778 13120 NCCI
77778 13121 NCCI
77778 13122 NCCI
77778 13131 NCCI
77778 13132 NCCI
77778 13133 NCCI
77778 13150 NCCI
77778 13151 NCCI
77778 13152 NCCI
77778 13153 NCCI
77778 16000 NCCI
77778 16020 NCCI
77778 16025 NCCI
77778 16030 NCCI
77778 36000 NCCI
77778 36400 NCCI
77778 36405 NCCI
77778 36406 NCCI
77778 36410 NCCI
77778 36420 NCCI
77778 36425 NCCI
77778 36430 NCCI
77778 36440 NCCI
77778 36600 NCCI
77778 36640 NCCI
77778 37202 NCCI
77778 43752 NCCI
77778 51701 NCCI
77778 51702 NCCI
77778 51703 NCCI
77778 62310 NCCI
77778 62311 NCCI
77778 62318 NCCI
77778 62319 NCCI
77778 64400 NCCI
77778 64402 NCCI
77778 64405 NCCI
77778 64408 NCCI
77778 64410 NCCI
77778 64412 NCCI
77778 64413 NCCI
77778 64415 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 168 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77778 64416 NCCI
77778 64417 NCCI
77778 64418 NCCI
77778 64420 NCCI
77778 64421 NCCI
77778 64425 NCCI
77778 64430 NCCI
77778 64435 NCCI
77778 64445 NCCI
77778 64446 NCCI
77778 64447 NCCI
77778 64448 NCCI
77778 64449 NCCI
77778 64450 NCCI
77778 64479 NCCI
77778 64483 NCCI
77778 64490 NCCI
77778 64493 NCCI
77778 64505 NCCI
77778 64508 NCCI
77778 64510 NCCI
77778 64517 NCCI
77778 64520 NCCI
77778 64530 NCCI
77778 76873 NCCI
77778 77336 NCCI
77778 77427 NCCI
77778 77431 NCCI
77778 77761 NCCI
77778 77762 NCCI
77778 77763 NCCI
77778 77776 NCCI
77778 77777 NCCI
77778 77785 NCCI
77778 77786 NCCI
77778 77787 NCCI
77778 77789 NCCI
77778 78012 NCCI
77778 78013 NCCI
77778 78014 NCCI
77778 78071 NCCI
77778 78072 NCCI
77778 78226 NCCI
77778 78227 NCCI
77778 78579 NCCI
77778 78582 NCCI
77778 78597 NCCI
Comprehensive ComponentCode Code Source
77778 78598 NCCI
77778 79300 NCCI
77778 79445 NCCI
77778 90832 NCCI
77778 90833 NCCI
77778 90834 NCCI
77778 90836 NCCI
77778 90837 NCCI
77778 90838 NCCI
77778 90839 NCCI
77778 90846 NCCI
77778 90847 NCCI
77778 93000 NCCI
77778 93005 NCCI
77778 93010 NCCI
77778 93040 NCCI
77778 93041 NCCI
77778 93042 NCCI
77778 93318 NCCI
77778 94002 NCCI
77778 94200 NCCI
77778 94250 NCCI
77778 94680 NCCI
77778 94681 NCCI
77778 94690 NCCI
77778 94770 NCCI
77778 95812 NCCI
77778 95813 NCCI
77778 95816 NCCI
77778 95819 NCCI
77778 95822 NCCI
77778 95829 NCCI
77778 95955 NCCI
77778 96360 NCCI
77778 96361 NCCI
77778 96365 NCCI
77778 96366 NCCI
77778 96367 NCCI
77778 96368 NCCI
77778 96372 NCCI
77778 96374 NCCI
77778 96375 NCCI
77778 96376 NCCI
77778 97802 NCCI
77778 97803 NCCI
77778 97804 NCCI
77778 99143 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 169 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77778 99144 NCCI
77778 99145 NCCI
77778 99148 NCCI
77778 99149 NCCI
77778 99150 NCCI
77778 99201 NCCI
77778 99202 NCCI
77778 99203 NCCI
77778 99204 NCCI
77778 99205 NCCI
77778 99211 NCCI
77778 99212 NCCI
77778 99213 NCCI
77778 99214 NCCI
77778 99215 NCCI
77778 99217 NCCI
77778 99218 NCCI
77778 99219 NCCI
77778 99220 NCCI
77778 99221 NCCI
77778 99222 NCCI
77778 99223 NCCI
77778 99224 NCCI
77778 99225 NCCI
77778 99226 NCCI
77778 99231 NCCI
77778 99232 NCCI
77778 99233 NCCI
77778 99234 NCCI
77778 99235 NCCI
77778 99236 NCCI
77778 99238 NCCI
77778 99239 NCCI
77778 99241 NCCI
77778 99241 NCCI
77778 99242 NCCI
77778 99244 NCCI
77778 99251 NCCI
77778 99252 NCCI
77778 99254 NCCI
77778 99255 NCCI
77778 99281 NCCI
77778 99282 NCCI
77778 99283 NCCI
77778 99284 NCCI
77778 99285 NCCI
77778 99291 NCCI
Comprehensive ComponentCode Code Source
77778 99292 NCCI
77778 99304 NCCI
77778 99305 NCCI
77778 99306 NCCI
77778 99307 NCCI
77778 99308 NCCI
77778 99309 NCCI
77778 99310 NCCI
77778 99315 NCCI
77778 99316 NCCI
77778 99318 NCCI
77778 99324 NCCI
77778 99325 NCCI
77778 99326 NCCI
77778 99327 NCCI
77778 99328 NCCI
77778 99334 NCCI
77778 99335 NCCI
77778 99336 NCCI
77778 99337 NCCI
77778 99341 NCCI
77778 99342 NCCI
77778 99343 NCCI
77778 99344 NCCI
77778 99345 NCCI
77778 99347 NCCI
77778 99348 NCCI
77778 99349 NCCI
77778 99350 NCCI
77778 99354 NCCI
77778 99355 NCCI
77778 99356 NCCI
77778 99357 NCCI
77778 99360 NCCI
77778 99374 NCCI
77778 99375 NCCI
77778 99377 NCCI
77778 99378 NCCI
77778 99455 NCCI
77778 99456 NCCI
77778 99460 NCCI
77778 99461 NCCI
77778 99462 NCCI
77778 99463 NCCI
77778 99464 NCCI
77778 99465 NCCI
77778 99466 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 170 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77778 99467 NCCI
77778 99468 NCCI
77778 99469 NCCI
77778 99471 NCCI
77778 99472 NCCI
77778 99475 NCCI
77778 99476 NCCI
77778 99477 NCCI
77778 99478 NCCI
77778 99479 NCCI
77778 99480 NCCI
77778 99485 NCCI
77778 G0459 NCCI
77778 M0064 NCCI
77785 0182T NCCI
77785 11920 NCCI
77785 11921 NCCI
77785 16000 NCCI
77785 16020 NCCI
77785 16025 NCCI
77785 16030 NCCI
77785 36000 NCCI
77785 36410 NCCI
77785 36425 NCCI
77785 51701 NCCI
77785 51702 NCCI
77785 51703 NCCI
77785 76000 NCCI
77785 76001 NCCI
77785 76645 NCCI
77785 76873 NCCI
77785 76942 NCCI
77785 77001 NCCI
77785 77002 NCCI
77785 77012 NCCI
77785 77021 NCCI
77785 77031 NCCI
77785 77032 NCCI
77785 77336 NCCI
77785 77427 NCCI
77785 77431 NCCI
77785 77790 NCCI
77785 78012 NCCI
77785 78013 NCCI
77785 78014 NCCI
77785 78015 NCCI
77785 78016 NCCI
Comprehensive ComponentCode Code Source
77785 78018 NCCI
77785 78070 NCCI
77785 78072 NCCI
77785 78075 NCCI
77785 78102 NCCI
77785 78103 NCCI
77785 78104 NCCI
77785 78110 NCCI
77785 78111 NCCI
77785 78120 NCCI
77785 78121 NCCI
77785 78122 NCCI
77785 78130 NCCI
77785 78135 NCCI
77785 78140 NCCI
77785 78185 NCCI
77785 78190 NCCI
77785 78191 NCCI
77785 78195 NCCI
77785 78201 NCCI
77785 78202 NCCI
77785 78205 NCCI
77785 78215 NCCI
77785 78216 NCCI
77785 78226 NCCI
77785 78230 NCCI
77785 78231 NCCI
77785 78232 NCCI
77785 78258 NCCI
77785 78261 NCCI
77785 78262 NCCI
77785 78264 NCCI
77785 78270 NCCI
77785 78271 NCCI
77785 78272 NCCI
77785 78278 NCCI
77785 78282 NCCI
77785 78290 NCCI
77785 78291 NCCI
77785 78300 NCCI
77785 78305 NCCI
77785 78306 NCCI
77785 78315 NCCI
77785 78320 NCCI
77785 78414 NCCI
77785 78428 NCCI
77785 78445 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 171 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77785 78457 NCCI
77785 78458 NCCI
77785 78466 NCCI
77785 78468 NCCI
77785 78469 NCCI
77785 78472 NCCI
77785 78473 NCCI
77785 78481 NCCI
77785 78483 NCCI
77785 78579 NCCI
77785 78580 NCCI
77785 78582 NCCI
77785 78597 NCCI
77785 78598 NCCI
77785 78600 NCCI
77785 78601 NCCI
77785 78605 NCCI
77785 78606 NCCI
77785 78607 NCCI
77785 78610 NCCI
77785 78630 NCCI
77785 78635 NCCI
77785 78645 NCCI
77785 78647 NCCI
77785 78650 NCCI
77785 78660 NCCI
77785 78700 NCCI
77785 78701 NCCI
77785 78707 NCCI
77785 78710 NCCI
77785 78725 NCCI
77785 78740 NCCI
77785 78761 NCCI
77785 78800 NCCI
77785 78801 NCCI
77785 78802 NCCI
77785 78803 NCCI
77785 78805 NCCI
77785 78806 NCCI
77785 78807 NCCI
77785 79200 NCCI
77785 79300 NCCI
77785 79440 NCCI
77785 90832 NCCI
77785 90833 NCCI
77785 90834 NCCI
77785 90836 NCCI
Comprehensive ComponentCode Code Source
77785 90837 NCCI
77785 90838 NCCI
77785 90839 NCCI
77785 90846 NCCI
77785 90847 NCCI
77785 96360 NCCI
77785 96361 NCCI
77785 96365 NCCI
77785 96366 NCCI
77785 96367 NCCI
77785 96368 NCCI
77785 97802 NCCI
77785 97803 NCCI
77785 97804 NCCI
77785 99143 NCCI
77785 99144 NCCI
77785 99145 NCCI
77785 G0459 NCCI
77785 M0064 NCCI
77786 0182T NCCI
77786 11920 NCCI
77786 11921 NCCI
77786 16000 NCCI
77786 16020 NCCI
77786 16025 NCCI
77786 16030 NCCI
77786 36000 NCCI
77786 36410 NCCI
77786 36425 NCCI
77786 51701 NCCI
77786 51702 NCCI
77786 51703 NCCI
77786 76000 NCCI
77786 76001 NCCI
77786 76645 NCCI
77786 76873 NCCI
77786 76942 NCCI
77786 77001 NCCI
77786 77002 NCCI
77786 77012 NCCI
77786 77021 NCCI
77786 77031 NCCI
77786 77032 NCCI
77786 77336 NCCI
77786 77427 NCCI
77786 77431 NCCI
77786 77785 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 172 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77786 77790 NCCI
77786 78012 NCCI
77786 78013 NCCI
77786 78014 NCCI
77786 78015 NCCI
77786 78016 NCCI
77786 78018 NCCI
77786 78070 NCCI
77786 78071 NCCI
77786 78072 NCCI
77786 78075 NCCI
77786 78102 NCCI
77786 78104 NCCI
77786 78110 NCCI
77786 78111 NCCI
77786 78120 NCCI
77786 78121 NCCI
77786 78122 NCCI
77786 78130 NCCI
77786 78135 NCCI
77786 78140 NCCI
77786 78185 NCCI
77786 78190 NCCI
77786 78191 NCCI
77786 78195 NCCI
77786 78201 NCCI
77786 78202 NCCI
77786 78205 NCCI
77786 78215 NCCI
77786 78216 NCCI
77786 78226 NCCI
77786 78230 NCCI
77786 78231 NCCI
77786 78232 NCCI
77786 78258 NCCI
77786 78261 NCCI
77786 78262 NCCI
77786 78264 NCCI
77786 78270 NCCI
77786 78271 NCCI
77786 78272 NCCI
77786 78278 NCCI
77786 78282 NCCI
77786 78290 NCCI
77786 78291 NCCI
77786 78300 NCCI
77786 78305 NCCI
Comprehensive ComponentCode Code Source
77786 78306 NCCI
77786 78315 NCCI
77786 78320 NCCI
77786 78414 NCCI
77786 78428 NCCI
77786 78445 NCCI
77786 78457 NCCI
77786 78458 NCCI
77786 78466 NCCI
77786 78468 NCCI
77786 78469 NCCI
77786 78472 NCCI
77786 78473 NCCI
77786 78481 NCCI
77786 78483 NCCI
77786 78579 NCCI
77786 78580 NCCI
77786 78582 NCCI
77786 78597 NCCI
77786 78598 NCCI
77786 78600 NCCI
77786 78601 NCCI
77786 78605 NCCI
77786 78606 NCCI
77786 78607 NCCI
77786 78610 NCCI
77786 78630 NCCI
77786 78635 NCCI
77786 78645 NCCI
77786 78647 NCCI
77786 78650 NCCI
77786 78660 NCCI
77786 78700 NCCI
77786 78701 NCCI
77786 78707 NCCI
77786 78710 NCCI
77786 78725 NCCI
77786 78740 NCCI
77786 78761 NCCI
77786 78800 NCCI
77786 78801 NCCI
77786 78802 NCCI
77786 78803 NCCI
77786 78805 NCCI
77786 78806 NCCI
77786 78807 NCCI
77786 79200 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 173 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77786 79300 NCCI
77786 79440 NCCI
77786 90832 NCCI
77786 90833 NCCI
77786 90834 NCCI
77786 90836 NCCI
77786 90837 NCCI
77786 90838 NCCI
77786 90839 NCCI
77786 90846 NCCI
77786 90847 NCCI
77786 96360 NCCI
77786 96361 NCCI
77786 96365 NCCI
77786 96366 NCCI
77786 96367 NCCI
77786 96368 NCCI
77786 97802 NCCI
77786 97803 NCCI
77786 97804 NCCI
77786 99143 NCCI
77786 99144 NCCI
77786 99145 NCCI
77786 G0459 NCCI
77786 M0064 NCCI
77787 0182T NCCI
77787 11920 NCCI
77787 11921 NCCI
77787 16000 NCCI
77787 16020 NCCI
77787 16025 NCCI
77787 16030 NCCI
77787 36000 NCCI
77787 36410 NCCI
77787 36425 NCCI
77787 51701 NCCI
77787 51702 NCCI
77787 51703 NCCI
77787 76000 NCCI
77787 76001 NCCI
77787 76645 NCCI
77787 76873 NCCI
77787 76942 NCCI
77787 77001 NCCI
77787 77002 NCCI
77787 77012 NCCI
77787 77021 NCCI
Comprehensive ComponentCode Code Source
77787 77031 NCCI
77787 77032 NCCI
77787 77336 NCCI
77787 77427 NCCI
77787 77431 NCCI
77787 77785 NCCI
77787 77786 NCCI
77787 77790 NCCI
77787 78012 NCCI
77787 78013 NCCI
77787 78014 NCCI
77787 78015 NCCI
77787 78016 NCCI
77787 78018 NCCI
77787 78070 NCCI
77787 78071 NCCI
77787 78072 NCCI
77787 78075 NCCI
77787 78102 NCCI
77787 78104 NCCI
77787 78110 NCCI
77787 78111 NCCI
77787 78120 NCCI
77787 78121 NCCI
77787 78122 NCCI
77787 78130 NCCI
77787 78135 NCCI
77787 78140 NCCI
77787 78185 NCCI
77787 78190 NCCI
77787 78191 NCCI
77787 78195 NCCI
77787 78201 NCCI
77787 78202 NCCI
77787 78205 NCCI
77787 78215 NCCI
77787 78216 NCCI
77787 78226 NCCI
77787 78230 NCCI
77787 78231 NCCI
77787 78232 NCCI
77787 78258 NCCI
77787 78261 NCCI
77787 78262 NCCI
77787 78264 NCCI
77787 78270 NCCI
77787 78271 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 174 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77787 78272 NCCI
77787 78278 NCCI
77787 78282 NCCI
77787 78290 NCCI
77787 78291 NCCI
77787 78300 NCCI
77787 78305 NCCI
77787 78306 NCCI
77787 78315 NCCI
77787 78320 NCCI
77787 78414 NCCI
77787 78428 NCCI
77787 78445 NCCI
77787 78457 NCCI
77787 78458 NCCI
77787 78466 NCCI
77787 78468 NCCI
77787 78469 NCCI
77787 78472 NCCI
77787 78473 NCCI
77787 78481 NCCI
77787 78483 NCCI
77787 78579 NCCI
77787 78580 NCCI
77787 78582 NCCI
77787 78597 NCCI
77787 78598 NCCI
77787 78600 NCCI
77787 78601 NCCI
77787 78605 NCCI
77787 78606 NCCI
77787 78607 NCCI
77787 78610 NCCI
77787 78630 NCCI
77787 78635 NCCI
77787 78645 NCCI
77787 78647 NCCI
77787 78650 NCCI
77787 78660 NCCI
77787 78700 NCCI
77787 78701 NCCI
77787 78707 NCCI
77787 78710 NCCI
77787 78725 NCCI
77787 78740 NCCI
77787 78761 NCCI
77787 78800 NCCI
Comprehensive ComponentCode Code Source
77787 78801 NCCI
77787 78802 NCCI
77787 78803 NCCI
77787 78805 NCCI
77787 78806 NCCI
77787 78807 NCCI
77787 79200 NCCI
77787 79300 NCCI
77787 79440 NCCI
77787 90832 NCCI
77787 90833 NCCI
77787 90834 NCCI
77787 90836 NCCI
77787 90837 NCCI
77787 90838 NCCI
77787 90839 NCCI
77787 90846 NCCI
77787 90847 NCCI
77787 96360 NCCI
77787 96361 NCCI
77787 96365 NCCI
77787 96366 NCCI
77787 96367 NCCI
77787 96368 NCCI
77787 97802 NCCI
77787 97803 NCCI
77787 97804 NCCI
77787 99143 NCCI
77787 99144 NCCI
77787 99145 NCCI
77787 G0459 NCCI
77787 M0064 NCCI
77789 0182T NCCI
77789 0213T NCCI
77789 0216T NCCI
77789 0228T NCCI
77789 0230T NCCI
77789 11920 NCCI
77789 11921 NCCI
77789 12001 NCCI
77789 12002 NCCI
77789 12004 NCCI
77789 12005 NCCI
77789 12006 NCCI
77789 12007 NCCI
77789 12011 NCCI
77789 12013 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 175 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77789 12014 NCCI
77789 12015 NCCI
77789 12016 NCCI
77789 12017 NCCI
77789 12018 NCCI
77789 12020 NCCI
77789 12021 NCCI
77789 12031 NCCI
77789 12032 NCCI
77789 12034 NCCI
77789 12035 NCCI
77789 12036 NCCI
77789 12037 NCCI
77789 12041 NCCI
77789 12042 NCCI
77789 12044 NCCI
77789 12045 NCCI
77789 12046 NCCI
77789 12047 NCCI
77789 12051 NCCI
77789 12052 NCCI
77789 12053 NCCI
77789 12054 NCCI
77789 12055 NCCI
77789 12056 NCCI
77789 12057 NCCI
77789 13100 NCCI
77789 13101 NCCI
77789 13102 NCCI
77789 13120 NCCI
77789 13121 NCCI
77789 13122 NCCI
77789 13131 NCCI
77789 13132 NCCI
77789 13133 NCCI
77789 13150 NCCI
77789 13151 NCCI
77789 13152 NCCI
77789 13153 NCCI
77789 16000 NCCI
77789 16020 NCCI
77789 16025 NCCI
77789 16030 NCCI
77789 36000 NCCI
77789 36400 NCCI
77789 36405 NCCI
77789 36406 NCCI
Comprehensive ComponentCode Code Source
77789 36410 NCCI
77789 36420 NCCI
77789 36425 NCCI
77789 36430 NCCI
77789 36440 NCCI
77789 36600 NCCI
77789 36640 NCCI
77789 37202 NCCI
77789 43752 NCCI
77789 51701 NCCI
77789 51702 NCCI
77789 51703 NCCI
77789 62310 NCCI
77789 62311 NCCI
77789 62318 NCCI
77789 62319 NCCI
77789 64400 NCCI
77789 64402 NCCI
77789 64405 NCCI
77789 64408 NCCI
77789 64410 NCCI
77789 64412 NCCI
77789 64413 NCCI
77789 64415 NCCI
77789 64416 NCCI
77789 64417 NCCI
77789 64418 NCCI
77789 64420 NCCI
77789 64421 NCCI
77789 64425 NCCI
77789 64430 NCCI
77789 64435 NCCI
77789 64445 NCCI
77789 64446 NCCI
77789 64447 NCCI
77789 64448 NCCI
77789 64449 NCCI
77789 64450 NCCI
77789 64479 NCCI
77789 64483 NCCI
77789 64490 NCCI
77789 64493 NCCI
77789 64505 NCCI
77789 64508 NCCI
77789 64510 NCCI
77789 64517 NCCI
77789 64520 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 176 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77789 64530 NCCI
77789 76873 NCCI
77789 77336 NCCI
77789 77427 NCCI
77789 77431 NCCI
77789 78012 NCCI
77789 78072 NCCI
77789 78226 NCCI
77789 78227 NCCI
77789 78579 NCCI
77789 78582 NCCI
77789 78597 NCCI
77789 78598 NCCI
77789 90832 NCCI
77789 90833 NCCI
77789 90834 NCCI
77789 90836 NCCI
77789 90837 NCCI
77789 90838 NCCI
77789 90839 NCCI
77789 90846 NCCI
77789 90847 NCCI
77789 93000 NCCI
77789 93005 NCCI
77789 93010 NCCI
77789 93040 NCCI
77789 93041 NCCI
77789 93042 NCCI
77789 93318 NCCI
77789 94002 NCCI
77789 94200 NCCI
77789 94250 NCCI
77789 94680 NCCI
77789 94681 NCCI
77789 94690 NCCI
77789 94770 NCCI
77789 95812 NCCI
77789 95813 NCCI
77789 95816 NCCI
77789 95819 NCCI
77789 95822 NCCI
77789 95829 NCCI
77789 95955 NCCI
77789 96360 NCCI
77789 96361 NCCI
77789 96365 NCCI
77789 96366 NCCI
Comprehensive ComponentCode Code Source
77789 96367 NCCI
77789 96368 NCCI
77789 96372 NCCI
77789 96374 NCCI
77789 96375 NCCI
77789 96376 NCCI
77789 97802 NCCI
77789 97803 NCCI
77789 97804 NCCI
77789 99143 NCCI
77789 99144 NCCI
77789 99145 NCCI
77789 99148 NCCI
77789 99149 NCCI
77789 99150 NCCI
77789 99201 NCCI
77789 99202 NCCI
77789 99203 NCCI
77789 99204 NCCI
77789 99205 NCCI
77789 99211 NCCI
77789 99212 NCCI
77789 99213 NCCI
77789 99214 NCCI
77789 99215 NCCI
77789 99217 NCCI
77789 99218 NCCI
77789 99219 NCCI
77789 99220 NCCI
77789 99221 NCCI
77789 99222 NCCI
77789 99223 NCCI
77789 99224 NCCI
77789 99225 NCCI
77789 99226 NCCI
77789 99231 NCCI
77789 99232 NCCI
77789 99233 NCCI
77789 99234 NCCI
77789 99235 NCCI
77789 99236 NCCI
77789 99238 NCCI
77789 99239 NCCI
77789 99241 NCCI
77789 99242 NCCI
77789 99243 NCCI
77789 99243 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 177 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77789 99245 NCCI
77789 99251 NCCI
77789 99252 NCCI
77789 99253 NCCI
77789 99254 NCCI
77789 99255 NCCI
77789 99281 NCCI
77789 99282 NCCI
77789 99283 NCCI
77789 99284 NCCI
77789 99285 NCCI
77789 99291 NCCI
77789 99292 NCCI
77789 99304 NCCI
77789 99305 NCCI
77789 99306 NCCI
77789 99307 NCCI
77789 99308 NCCI
77789 99309 NCCI
77789 99310 NCCI
77789 99315 NCCI
77789 99316 NCCI
77789 99318 NCCI
77789 99324 NCCI
77789 99325 NCCI
77789 99326 NCCI
77789 99327 NCCI
77789 99328 NCCI
77789 99334 NCCI
77789 99335 NCCI
77789 99336 NCCI
77789 99337 NCCI
77789 99341 NCCI
77789 99342 NCCI
77789 99343 NCCI
77789 99344 NCCI
77789 99345 NCCI
77789 99347 NCCI
77789 99348 NCCI
77789 99349 NCCI
77789 99350 NCCI
77789 99354 NCCI
77789 99355 NCCI
77789 99356 NCCI
77789 99357 NCCI
77789 99360 NCCI
77789 99374 NCCI
Comprehensive ComponentCode Code Source
77789 99375 NCCI
77789 99377 NCCI
77789 99378 NCCI
77789 99455 NCCI
77789 99456 NCCI
77789 99460 NCCI
77789 99461 NCCI
77789 99462 NCCI
77789 99463 NCCI
77789 99464 NCCI
77789 99465 NCCI
77789 99466 NCCI
77789 99467 NCCI
77789 99468 NCCI
77789 99469 NCCI
77789 99471 NCCI
77789 99472 NCCI
77789 99475 NCCI
77789 99476 NCCI
77789 99477 NCCI
77789 99478 NCCI
77789 99479 NCCI
77789 99480 NCCI
77789 99485 NCCI
77789 G0459 NCCI
77789 J0670 NCCI
77789 J2001 NCCI
77789 M0064 NCCI
77790 11920 NCCI
77790 11921 NCCI
77790 16000 NCCI
77790 16020 NCCI
77790 16025 NCCI
77790 16030 NCCI
77790 36000 NCCI
77790 36410 NCCI
77790 36425 NCCI
77790 51701 NCCI
77790 51702 NCCI
77790 51703 NCCI
77790 76873 NCCI
77790 77336 NCCI
77790 77427 NCCI
77790 77431 NCCI
77790 78012 NCCI
77790 78072 NCCI
77790 78226 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 178 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77790 78227 NCCI
77790 78579 NCCI
77790 78582 NCCI
77790 78597 NCCI
77790 78598 NCCI
77790 90832 NCCI
77790 90833 NCCI
77790 90834 NCCI
77790 90836 NCCI
77790 90837 NCCI
77790 90838 NCCI
77790 90839 NCCI
77790 90846 NCCI
77790 90847 NCCI
77790 96360 NCCI
77790 96361 NCCI
77790 96365 NCCI
77790 96366 NCCI
77790 96367 NCCI
77790 96368 NCCI
77790 97802 NCCI
77790 97803 NCCI
77790 97804 NCCI
77790 99143 NCCI
77790 99144 NCCI
77790 99145 NCCI
77790 99201 NCCI
77790 99202 NCCI
77790 99203 NCCI
77790 99204 NCCI
77790 99205 NCCI
77790 99211 NCCI
77790 99212 NCCI
77790 99213 NCCI
77790 99214 NCCI
77790 99215 NCCI
77790 99217 NCCI
77790 99218 NCCI
77790 99219 NCCI
77790 99220 NCCI
77790 99221 NCCI
77790 99222 NCCI
77790 99223 NCCI
77790 99224 NCCI
77790 99225 NCCI
77790 99226 NCCI
77790 99231 NCCI
Comprehensive ComponentCode Code Source
77790 99232 NCCI
77790 99233 NCCI
77790 99234 NCCI
77790 99235 NCCI
77790 99236 NCCI
77790 99238 NCCI
77790 99239 NCCI
77790 99281 NCCI
77790 99282 NCCI
77790 99283 NCCI
77790 99284 NCCI
77790 99285 NCCI
77790 99291 NCCI
77790 99292 NCCI
77790 99304 NCCI
77790 99305 NCCI
77790 99306 NCCI
77790 99307 NCCI
77790 99308 NCCI
77790 99309 NCCI
77790 99310 NCCI
77790 99315 NCCI
77790 99316 NCCI
77790 99318 NCCI
77790 99324 NCCI
77790 99325 NCCI
77790 99326 NCCI
77790 99327 NCCI
77790 99328 NCCI
77790 99334 NCCI
77790 99335 NCCI
77790 99336 NCCI
77790 99337 NCCI
77790 99341 NCCI
77790 99342 NCCI
77790 99343 NCCI
77790 99344 NCCI
77790 99345 NCCI
77790 99347 NCCI
77790 99348 NCCI
77790 99349 NCCI
77790 99350 NCCI
77790 99354 NCCI
77790 99355 NCCI
77790 99356 NCCI
77790 99357 NCCI
77790 99360 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 179 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
77790 99455 NCCI
77790 99456 NCCI
77790 99460 NCCI
77790 99461 NCCI
77790 99462 NCCI
77790 99463 NCCI
77790 99464 NCCI
77790 99465 NCCI
77790 99466 NCCI
77790 99467 NCCI
77790 99468 NCCI
77790 99469 NCCI
77790 99471 NCCI
77790 99472 NCCI
77790 99475 NCCI
77790 99476 NCCI
77790 99477 NCCI
77790 99478 NCCI
77790 99479 NCCI
77790 99480 NCCI
77790 99485 NCCI
77790 G0459 NCCI
77790 M0064 NCCI
78000 78000 CPT
78001 78001 CPT
78003 78003 CPT
78006 78006 CPT
78007 78007 CPT
78010 78010 CPT
78011 78011 CPT
78012 36000 NCCI
78012 36005 NCCI
78012 36410 NCCI
78012 76000 NCCI
78012 76001 NCCI
78012 76376 NCCI
78012 76377 NCCI
78012 76942 NCCI
78012 76998 NCCI
78012 77001 NCCI
78012 77002 NCCI
78012 78445 NCCI
78012 96360 NCCI
78012 96365 NCCI
78012 96372 NCCI
78012 96374 NCCI
78012 96375 NCCI
Comprehensive ComponentCode Code Source
78012 96376 NCCI
78013 36000 NCCI
78013 36005 NCCI
78013 36410 NCCI
78013 76000 NCCI
78013 76001 NCCI
78013 76376 NCCI
78013 76377 NCCI
78013 76942 NCCI
78013 76998 NCCI
78013 77001 NCCI
78013 77002 NCCI
78013 77789 NCCI
78013 77790 NCCI
78013 78012 NCCI
78013 78445 NCCI
78013 96360 NCCI
78013 96365 NCCI
78013 96372 NCCI
78013 96374 NCCI
78013 96375 NCCI
78013 96376 NCCI
78013 J1642 NCCI
78014 36000 NCCI
78014 36005 NCCI
78014 36410 NCCI
78014 76000 NCCI
78014 76001 NCCI
78014 76376 NCCI
78014 76377 NCCI
78014 76942 NCCI
78014 76998 NCCI
78014 77001 NCCI
78014 77002 NCCI
78014 77789 NCCI
78014 77790 NCCI
78014 78012 NCCI
78014 78013 NCCI
78014 78015 NCCI
78014 78445 NCCI
78014 96360 NCCI
78014 96365 NCCI
78014 96372 NCCI
78014 96374 NCCI
78014 96375 NCCI
78014 96376 NCCI
78014 J1642 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 180 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78015 36000 NCCI
78015 36005 NCCI
78015 36410 NCCI
78015 76000 NCCI
78015 76001 NCCI
78015 76376 NCCI
78015 76377 NCCI
78015 76942 NCCI
78015 76998 NCCI
78015 77001 NCCI
78015 77002 NCCI
78015 77750 NCCI
78015 77761 NCCI
78015 77762 NCCI
78015 77763 NCCI
78015 77776 NCCI
78015 77777 NCCI
78015 77778 NCCI
78015 77789 NCCI
78015 77790 NCCI
78015 78012 NCCI
78015 78013 NCCI
78015 78015 CPT
78015 78445 NCCI
78015 96360 NCCI
78015 96365 NCCI
78015 96372 NCCI
78015 96374 NCCI
78015 96375 NCCI
78015 96376 NCCI
78015 J1642 NCCI
78016 36000 NCCI
78016 36005 NCCI
78016 36410 NCCI
78016 76000 NCCI
78016 76001 NCCI
78016 76376 NCCI
78016 76377 NCCI
78016 76942 NCCI
78016 76998 NCCI
78016 77001 NCCI
78016 77002 NCCI
78016 77750 NCCI
78016 77761 NCCI
78016 77762 NCCI
78016 77763 NCCI
78016 77776 NCCI
Comprehensive ComponentCode Code Source
78016 77777 NCCI
78016 77778 NCCI
78016 77789 NCCI
78016 77790 NCCI
78016 78015 NCCI
78016 78016 CPT
78016 78445 NCCI
78016 96360 NCCI
78016 96365 NCCI
78016 96372 NCCI
78016 96374 NCCI
78016 96375 NCCI
78016 96376 NCCI
78016 J1642 NCCI
78018 36000 NCCI
78018 36005 NCCI
78018 36410 NCCI
78018 76000 NCCI
78018 76001 NCCI
78018 76376 NCCI
78018 76377 NCCI
78018 76942 NCCI
78018 76998 NCCI
78018 77001 NCCI
78018 77002 NCCI
78018 77750 NCCI
78018 77761 NCCI
78018 77762 NCCI
78018 77763 NCCI
78018 77776 NCCI
78018 77777 NCCI
78018 77778 NCCI
78018 77789 NCCI
78018 77790 NCCI
78018 78015 NCCI
78018 78018 CPT
78018 78445 NCCI
78018 96360 NCCI
78018 96365 NCCI
78018 96372 NCCI
78018 96374 NCCI
78018 96375 NCCI
78018 96376 NCCI
78018 J1642 NCCI
78020 36005 NCCI
78020 36410 NCCI
78020 78020 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: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 181 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78020 78445 NCCI
78070 36000 NCCI
78070 36005 NCCI
78070 36410 NCCI
78070 76000 NCCI
78070 76001 NCCI
78070 76376 NCCI
78070 76377 NCCI
78070 76942 NCCI
78070 76998 NCCI
78070 77001 NCCI
78070 77002 NCCI
78070 77750 NCCI
78070 77761 NCCI
78070 77762 NCCI
78070 77763 NCCI
78070 77776 NCCI
78070 77777 NCCI
78070 77778 NCCI
78070 77789 NCCI
78070 77790 NCCI
78070 78070 BCBST
78070 78445 NCCI
78070 96360 NCCI
78070 96365 NCCI
78070 96372 NCCI
78070 96374 NCCI
78070 96375 NCCI
78070 96376 NCCI
78070 J1642 NCCI
78071 36000 NCCI
78071 36005 NCCI
78071 36410 NCCI
78071 76000 NCCI
78071 76001 NCCI
78071 76376 NCCI
78071 76377 NCCI
78071 76942 NCCI
78071 76998 NCCI
78071 77001 NCCI
78071 77002 NCCI
78071 77750 NCCI
78071 77785 NCCI
78071 77789 NCCI
78071 77790 NCCI
78071 78070 NCCI
78071 78445 NCCI
Comprehensive ComponentCode Code Source
78071 96360 NCCI
78071 96365 NCCI
78071 96372 NCCI
78071 96374 NCCI
78071 96375 NCCI
78071 96376 NCCI
78071 J1642 NCCI
78072 36000 NCCI
78072 36005 NCCI
78072 36410 NCCI
78072 76000 NCCI
78072 76001 NCCI
78072 76376 NCCI
78072 76377 NCCI
78072 76942 NCCI
78072 76998 NCCI
78072 77001 NCCI
78072 77002 NCCI
78072 78070 NCCI
78072 78071 NCCI
78072 78445 NCCI
78072 96360 NCCI
78072 96365 NCCI
78072 96372 NCCI
78072 96374 NCCI
78072 96375 NCCI
78072 96376 NCCI
78072 J1642 NCCI
78075 36000 NCCI
78075 36005 NCCI
78075 36410 NCCI
78075 76000 NCCI
78075 76001 NCCI
78075 76376 NCCI
78075 76377 NCCI
78075 76942 NCCI
78075 76998 NCCI
78075 77001 NCCI
78075 77002 NCCI
78075 77750 NCCI
78075 77761 NCCI
78075 77762 NCCI
78075 77763 NCCI
78075 77776 NCCI
78075 77777 NCCI
78075 77778 NCCI
78075 77789 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 182 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78075 77790 NCCI
78075 78075 BCBST
78075 78445 NCCI
78075 96360 NCCI
78075 96365 NCCI
78075 96372 NCCI
78075 96374 NCCI
78075 96375 NCCI
78075 96376 NCCI
78075 J1642 NCCI
78102 36000 NCCI
78102 36005 NCCI
78102 36410 NCCI
78102 76000 NCCI
78102 76001 NCCI
78102 76376 NCCI
78102 76377 NCCI
78102 76942 NCCI
78102 76998 NCCI
78102 77001 NCCI
78102 77002 NCCI
78102 77750 NCCI
78102 77761 NCCI
78102 77762 NCCI
78102 77763 NCCI
78102 77776 NCCI
78102 77777 NCCI
78102 77778 NCCI
78102 77789 NCCI
78102 77790 NCCI
78102 78102 CPT
78102 78445 NCCI
78102 96360 NCCI
78102 96365 NCCI
78102 96372 NCCI
78102 96374 NCCI
78102 96375 NCCI
78102 96376 NCCI
78102 J1642 NCCI
78103 36000 NCCI
78103 36005 NCCI
78103 36410 NCCI
78103 76000 NCCI
78103 76001 NCCI
78103 76376 NCCI
78103 76377 NCCI
78103 76942 NCCI
Comprehensive ComponentCode Code Source
78103 76998 NCCI
78103 77001 NCCI
78103 77002 NCCI
78103 77750 NCCI
78103 77761 NCCI
78103 77762 NCCI
78103 77763 NCCI
78103 77776 NCCI
78103 77777 NCCI
78103 77778 NCCI
78103 77789 NCCI
78103 77790 NCCI
78103 78102 NCCI
78103 78103 CPT
78103 78445 NCCI
78103 96360 NCCI
78103 96365 NCCI
78103 96372 NCCI
78103 96374 NCCI
78103 96375 NCCI
78103 96376 NCCI
78103 J1642 NCCI
78104 36000 NCCI
78104 36005 NCCI
78104 36410 NCCI
78104 76000 NCCI
78104 76001 NCCI
78104 76376 NCCI
78104 76377 NCCI
78104 76942 NCCI
78104 76998 NCCI
78104 77001 NCCI
78104 77002 NCCI
78104 77750 NCCI
78104 77761 NCCI
78104 77762 NCCI
78104 77763 NCCI
78104 77776 NCCI
78104 77777 NCCI
78104 77778 NCCI
78104 77789 NCCI
78104 77790 NCCI
78104 78102 NCCI
78104 78103 NCCI
78104 78104 CPT
78104 78445 NCCI
78104 96360 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 183 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78104 96365 NCCI
78104 96372 NCCI
78104 96374 NCCI
78104 96375 NCCI
78104 96376 NCCI
78104 J1642 NCCI
78110 36000 NCCI
78110 36005 NCCI
78110 36410 NCCI
78110 76000 NCCI
78110 76001 NCCI
78110 76376 NCCI
78110 76377 NCCI
78110 76942 NCCI
78110 76998 NCCI
78110 77001 NCCI
78110 77002 NCCI
78110 77750 NCCI
78110 77761 NCCI
78110 77762 NCCI
78110 77763 NCCI
78110 77776 NCCI
78110 77777 NCCI
78110 77778 NCCI
78110 77789 NCCI
78110 77790 NCCI
78110 78110 CPT
78110 78445 NCCI
78110 96360 NCCI
78110 96365 NCCI
78110 96372 NCCI
78110 96374 NCCI
78110 96375 NCCI
78110 96376 NCCI
78111 36000 NCCI
78111 36005 NCCI
78111 36410 NCCI
78111 76000 NCCI
78111 76001 NCCI
78111 76376 NCCI
78111 76377 NCCI
78111 76942 NCCI
78111 76998 NCCI
78111 77001 NCCI
78111 77002 NCCI
78111 77750 NCCI
78111 77761 NCCI
Comprehensive ComponentCode Code Source
78111 77762 NCCI
78111 77763 NCCI
78111 77776 NCCI
78111 77777 NCCI
78111 77778 NCCI
78111 77789 NCCI
78111 77790 NCCI
78111 78110 NCCI
78111 78111 CPT
78111 78445 NCCI
78111 96360 NCCI
78111 96365 NCCI
78111 96372 NCCI
78111 96374 NCCI
78111 96375 NCCI
78111 96376 NCCI
78120 36000 NCCI
78120 36005 NCCI
78120 36410 NCCI
78120 76000 NCCI
78120 76001 NCCI
78120 76376 NCCI
78120 76377 NCCI
78120 76942 NCCI
78120 76998 NCCI
78120 77001 NCCI
78120 77002 NCCI
78120 77750 NCCI
78120 77761 NCCI
78120 77762 NCCI
78120 77763 NCCI
78120 77776 NCCI
78120 77777 NCCI
78120 77778 NCCI
78120 77789 NCCI
78120 77790 NCCI
78120 78120 CPT
78120 78445 NCCI
78120 96360 NCCI
78120 96365 NCCI
78120 96372 NCCI
78120 96374 NCCI
78120 96375 NCCI
78120 96376 NCCI
78121 36000 NCCI
78121 36005 NCCI
78121 36410 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 184 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78121 76000 NCCI
78121 76001 NCCI
78121 76376 NCCI
78121 76377 NCCI
78121 76942 NCCI
78121 76998 NCCI
78121 77001 NCCI
78121 77002 NCCI
78121 77750 NCCI
78121 77761 NCCI
78121 77762 NCCI
78121 77763 NCCI
78121 77776 NCCI
78121 77777 NCCI
78121 77778 NCCI
78121 77789 NCCI
78121 77790 NCCI
78121 78120 NCCI
78121 78121 CPT
78121 78445 NCCI
78121 96360 NCCI
78121 96365 NCCI
78121 96372 NCCI
78121 96374 NCCI
78121 96375 NCCI
78121 96376 NCCI
78122 36000 NCCI
78122 36005 NCCI
78122 36410 NCCI
78122 76000 NCCI
78122 76001 NCCI
78122 76376 NCCI
78122 76377 NCCI
78122 76942 NCCI
78122 76998 NCCI
78122 77001 NCCI
78122 77002 NCCI
78122 77750 NCCI
78122 77761 NCCI
78122 77762 NCCI
78122 77763 NCCI
78122 77776 NCCI
78122 77777 NCCI
78122 77778 NCCI
78122 77789 NCCI
78122 77790 NCCI
78122 78110 NCCI
Comprehensive ComponentCode Code Source
78122 78111 NCCI
78122 78120 NCCI
78122 78121 NCCI
78122 78122 BCBST
78122 78445 NCCI
78122 96360 NCCI
78122 96365 NCCI
78122 96372 NCCI
78122 96374 NCCI
78122 96375 NCCI
78122 96376 NCCI
78130 36000 NCCI
78130 36005 NCCI
78130 36410 NCCI
78130 76000 NCCI
78130 76001 NCCI
78130 76376 NCCI
78130 76377 NCCI
78130 76942 NCCI
78130 76998 NCCI
78130 77001 NCCI
78130 77002 NCCI
78130 77750 NCCI
78130 77761 NCCI
78130 77762 NCCI
78130 77763 NCCI
78130 77776 NCCI
78130 77777 NCCI
78130 77778 NCCI
78130 77789 NCCI
78130 77790 NCCI
78130 78130 BCBST
78130 78445 NCCI
78130 96360 NCCI
78130 96365 NCCI
78130 96372 NCCI
78130 96374 NCCI
78130 96375 NCCI
78130 96376 NCCI
78135 36000 NCCI
78135 36005 NCCI
78135 36410 NCCI
78135 76000 NCCI
78135 76001 NCCI
78135 76376 NCCI
78135 76377 NCCI
78135 76942 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 185 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78135 76998 NCCI
78135 77001 NCCI
78135 77002 NCCI
78135 77750 NCCI
78135 77761 NCCI
78135 77762 NCCI
78135 77763 NCCI
78135 77776 NCCI
78135 77777 NCCI
78135 77778 NCCI
78135 77789 NCCI
78135 77790 NCCI
78135 78130 NCCI
78135 78135 BCBST
78135 78140 NCCI
78135 78445 NCCI
78135 96360 NCCI
78135 96365 NCCI
78135 96372 NCCI
78135 96374 NCCI
78135 96375 NCCI
78135 96376 NCCI
78135 J1642 NCCI
78140 36000 NCCI
78140 36005 NCCI
78140 36410 NCCI
78140 76000 NCCI
78140 76001 NCCI
78140 76376 NCCI
78140 76377 NCCI
78140 76942 NCCI
78140 76998 NCCI
78140 77001 NCCI
78140 77002 NCCI
78140 77750 NCCI
78140 77761 NCCI
78140 77762 NCCI
78140 77763 NCCI
78140 77776 NCCI
78140 77777 NCCI
78140 77778 NCCI
78140 77789 NCCI
78140 77790 NCCI
78140 78140 BCBST
78140 78445 NCCI
78140 96360 NCCI
78140 96365 NCCI
Comprehensive ComponentCode Code Source
78140 96372 NCCI
78140 96374 NCCI
78140 96375 NCCI
78140 96376 NCCI
78140 J1642 NCCI
78185 36000 NCCI
78185 36005 NCCI
78185 36410 NCCI
78185 76000 NCCI
78185 76001 NCCI
78185 76376 NCCI
78185 76377 NCCI
78185 76942 NCCI
78185 76998 NCCI
78185 77001 NCCI
78185 77002 NCCI
78185 77750 NCCI
78185 77761 NCCI
78185 77762 NCCI
78185 77763 NCCI
78185 77776 NCCI
78185 77777 NCCI
78185 77778 NCCI
78185 77789 NCCI
78185 77790 NCCI
78185 78185 BCBST
78185 78445 NCCI
78185 96360 NCCI
78185 96365 NCCI
78185 96372 NCCI
78185 96374 NCCI
78185 96375 NCCI
78185 96376 NCCI
78185 J1642 NCCI
78190 36000 NCCI
78190 36005 NCCI
78190 36410 NCCI
78190 76000 NCCI
78190 76001 NCCI
78190 76376 NCCI
78190 76377 NCCI
78190 76942 NCCI
78190 76998 NCCI
78190 77001 NCCI
78190 77002 NCCI
78190 77750 NCCI
78190 77761 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 186 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78190 77762 NCCI
78190 77763 NCCI
78190 77776 NCCI
78190 77777 NCCI
78190 77778 NCCI
78190 77789 NCCI
78190 77790 NCCI
78190 78190 BCBST
78190 78191 NCCI
78190 78445 NCCI
78190 96360 NCCI
78190 96365 NCCI
78190 96372 NCCI
78190 96374 NCCI
78190 96375 NCCI
78190 96376 NCCI
78190 J1642 NCCI
78191 36000 NCCI
78191 36005 NCCI
78191 36410 NCCI
78191 76000 NCCI
78191 76001 NCCI
78191 76376 NCCI
78191 76377 NCCI
78191 76942 NCCI
78191 76998 NCCI
78191 77001 NCCI
78191 77002 NCCI
78191 77750 NCCI
78191 77761 NCCI
78191 77762 NCCI
78191 77763 NCCI
78191 77776 NCCI
78191 77777 NCCI
78191 77778 NCCI
78191 77789 NCCI
78191 77790 NCCI
78191 78191 BCBST
78191 78445 NCCI
78191 96360 NCCI
78191 96365 NCCI
78191 96372 NCCI
78191 96374 NCCI
78191 96375 NCCI
78191 96376 NCCI
78195 36000 NCCI
78195 36005 NCCI
Comprehensive ComponentCode Code Source
78195 36410 NCCI
78195 38792 NCCI
78195 38792 BCBST
78195 76000 NCCI
78195 76001 NCCI
78195 76376 NCCI
78195 76377 NCCI
78195 76942 NCCI
78195 76998 NCCI
78195 77001 NCCI
78195 77002 NCCI
78195 77750 NCCI
78195 77761 NCCI
78195 77762 NCCI
78195 77763 NCCI
78195 77776 NCCI
78195 77777 NCCI
78195 77778 NCCI
78195 77789 NCCI
78195 77790 NCCI
78195 78195 BCBST
78195 78445 NCCI
78195 96360 NCCI
78195 96365 NCCI
78195 96372 NCCI
78195 96374 NCCI
78195 96375 NCCI
78195 96376 NCCI
78195 J1642 NCCI
78201 36000 NCCI
78201 36005 NCCI
78201 36410 NCCI
78201 76000 NCCI
78201 76001 NCCI
78201 76376 NCCI
78201 76377 NCCI
78201 76942 NCCI
78201 76998 NCCI
78201 77001 NCCI
78201 77002 NCCI
78201 77750 NCCI
78201 77761 NCCI
78201 77762 NCCI
78201 77763 NCCI
78201 77776 NCCI
78201 77777 NCCI
78201 77778 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 187 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78201 77789 NCCI
78201 77790 NCCI
78201 78201 BCBST
78201 78216 NCCI
78201 78445 NCCI
78201 96360 NCCI
78201 96365 NCCI
78201 96372 NCCI
78201 96374 NCCI
78201 96375 NCCI
78201 96376 NCCI
78201 J1642 NCCI
78202 36000 NCCI
78202 36005 NCCI
78202 36410 NCCI
78202 76000 NCCI
78202 76001 NCCI
78202 76376 NCCI
78202 76377 NCCI
78202 76942 NCCI
78202 76998 NCCI
78202 77001 NCCI
78202 77002 NCCI
78202 77750 NCCI
78202 77761 NCCI
78202 77762 NCCI
78202 77763 NCCI
78202 77776 NCCI
78202 77777 NCCI
78202 77778 NCCI
78202 77789 NCCI
78202 77790 NCCI
78202 78201 NCCI
78202 78202 BCBST
78202 78215 NCCI
78202 78216 NCCI
78202 78445 NCCI
78202 96360 NCCI
78202 96365 NCCI
78202 96372 NCCI
78202 96374 NCCI
78202 96375 NCCI
78202 96376 NCCI
78202 J1642 NCCI
78205 36000 NCCI
78205 36005 NCCI
78205 36410 NCCI
Comprehensive ComponentCode Code Source
78205 76000 NCCI
78205 76001 NCCI
78205 76376 NCCI
78205 76377 NCCI
78205 76942 NCCI
78205 76998 NCCI
78205 77001 NCCI
78205 77002 NCCI
78205 77750 NCCI
78205 77761 NCCI
78205 77762 NCCI
78205 77763 NCCI
78205 77776 NCCI
78205 77777 NCCI
78205 77778 NCCI
78205 77789 NCCI
78205 77790 NCCI
78205 78201 NCCI
78205 78202 NCCI
78205 78205 BCBST
78205 78215 NCCI
78205 78216 NCCI
78205 78445 NCCI
78205 96360 NCCI
78205 96365 NCCI
78205 96372 NCCI
78205 96374 NCCI
78205 96375 NCCI
78205 96376 NCCI
78205 J1642 NCCI
78206 36000 NCCI
78206 36005 NCCI
78206 36410 NCCI
78206 76000 NCCI
78206 76001 NCCI
78206 76376 NCCI
78206 76377 NCCI
78206 76942 NCCI
78206 76998 NCCI
78206 77001 NCCI
78206 77002 NCCI
78206 78201 NCCI
78206 78202 NCCI
78206 78205 NCCI
78206 78206 BCBST
78206 78215 NCCI
78206 78216 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 188 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78206 78445 NCCI
78206 96360 NCCI
78206 96365 NCCI
78206 96372 NCCI
78206 96374 NCCI
78206 96375 NCCI
78206 96376 NCCI
78215 36000 NCCI
78215 36005 NCCI
78215 36410 NCCI
78215 76000 NCCI
78215 76001 NCCI
78215 76376 NCCI
78215 76377 NCCI
78215 76942 NCCI
78215 76998 NCCI
78215 77001 NCCI
78215 77002 NCCI
78215 77750 NCCI
78215 77761 NCCI
78215 77762 NCCI
78215 77763 NCCI
78215 77776 NCCI
78215 77777 NCCI
78215 77778 NCCI
78215 77789 NCCI
78215 77790 NCCI
78215 78185 NCCI
78215 78201 NCCI
78215 78215 BCBST
78215 78216 NCCI
78215 78445 NCCI
78215 96360 NCCI
78215 96365 NCCI
78215 96372 NCCI
78215 96374 NCCI
78215 96375 NCCI
78215 96376 NCCI
78215 J1642 NCCI
78216 36000 NCCI
78216 36005 NCCI
78216 36410 NCCI
78216 76000 NCCI
78216 76001 NCCI
78216 76376 NCCI
78216 76377 NCCI
78216 76942 NCCI
Comprehensive ComponentCode Code Source
78216 76998 NCCI
78216 77001 NCCI
78216 77002 NCCI
78216 77750 NCCI
78216 77761 NCCI
78216 77762 NCCI
78216 77763 NCCI
78216 77776 NCCI
78216 77777 NCCI
78216 77778 NCCI
78216 77789 NCCI
78216 77790 NCCI
78216 78185 NCCI
78216 78216 BCBST
78216 78445 NCCI
78216 96360 NCCI
78216 96365 NCCI
78216 96372 NCCI
78216 96374 NCCI
78216 96375 NCCI
78216 96376 NCCI
78216 J1642 NCCI
78226 36000 NCCI
78226 36005 NCCI
78226 36410 NCCI
78226 76000 NCCI
78226 76001 NCCI
78226 76376 NCCI
78226 76377 NCCI
78226 76942 NCCI
78226 76998 NCCI
78226 77001 NCCI
78226 77002 NCCI
78226 78445 NCCI
78226 96360 NCCI
78226 96365 NCCI
78226 96372 NCCI
78226 96374 NCCI
78226 96375 NCCI
78226 96376 NCCI
78226 J1642 NCCI
78227 36000 NCCI
78227 36005 NCCI
78227 36410 NCCI
78227 76000 NCCI
78227 76001 NCCI
78227 76376 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 189 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78227 76377 NCCI
78227 76942 NCCI
78227 76998 NCCI
78227 77001 NCCI
78227 77002 NCCI
78227 77785 NCCI
78227 77786 NCCI
78227 77787 NCCI
78227 78226 NCCI
78227 78445 NCCI
78227 96360 NCCI
78227 96365 NCCI
78227 96372 NCCI
78227 96374 NCCI
78227 96375 NCCI
78227 96376 NCCI
78227 J1642 NCCI
78230 36000 NCCI
78230 36005 NCCI
78230 36410 NCCI
78230 76000 NCCI
78230 76001 NCCI
78230 76376 NCCI
78230 76377 NCCI
78230 76942 NCCI
78230 76998 NCCI
78230 77001 NCCI
78230 77002 NCCI
78230 77750 NCCI
78230 77761 NCCI
78230 77762 NCCI
78230 77763 NCCI
78230 77776 NCCI
78230 77777 NCCI
78230 77778 NCCI
78230 77789 NCCI
78230 77790 NCCI
78230 78230 BCBST
78230 78445 NCCI
78230 96360 NCCI
78230 96365 NCCI
78230 96372 NCCI
78230 96374 NCCI
78230 96375 NCCI
78230 96376 NCCI
78230 J1642 NCCI
78231 36000 NCCI
Comprehensive ComponentCode Code Source
78231 36005 NCCI
78231 36410 NCCI
78231 76000 NCCI
78231 76001 NCCI
78231 76376 NCCI
78231 76377 NCCI
78231 76942 NCCI
78231 76998 NCCI
78231 77001 NCCI
78231 77002 NCCI
78231 77750 NCCI
78231 77761 NCCI
78231 77762 NCCI
78231 77763 NCCI
78231 77776 NCCI
78231 77777 NCCI
78231 77778 NCCI
78231 77789 NCCI
78231 77790 NCCI
78231 78230 NCCI
78231 78231 BCBST
78231 78445 NCCI
78231 96360 NCCI
78231 96365 NCCI
78231 96372 NCCI
78231 96374 NCCI
78231 96375 NCCI
78231 96376 NCCI
78231 J1642 NCCI
78232 36000 NCCI
78232 36005 NCCI
78232 36410 NCCI
78232 76000 NCCI
78232 76001 NCCI
78232 76376 NCCI
78232 76377 NCCI
78232 76942 NCCI
78232 76998 NCCI
78232 77001 NCCI
78232 77002 NCCI
78232 77750 NCCI
78232 77761 NCCI
78232 77762 NCCI
78232 77763 NCCI
78232 77776 NCCI
78232 77777 NCCI
78232 77778 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 190 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78232 77789 NCCI
78232 77790 NCCI
78232 78232 BCBST
78232 78445 NCCI
78232 96360 NCCI
78232 96365 NCCI
78232 96372 NCCI
78232 96374 NCCI
78232 96375 NCCI
78232 96376 NCCI
78232 J1642 NCCI
78258 36000 NCCI
78258 36005 NCCI
78258 36410 NCCI
78258 76000 NCCI
78258 76001 NCCI
78258 76376 NCCI
78258 76377 NCCI
78258 76942 NCCI
78258 76998 NCCI
78258 77001 NCCI
78258 77002 NCCI
78258 77750 NCCI
78258 77761 NCCI
78258 77762 NCCI
78258 77763 NCCI
78258 77776 NCCI
78258 77777 NCCI
78258 77778 NCCI
78258 77789 NCCI
78258 77790 NCCI
78258 78258 BCBST
78258 78445 NCCI
78258 96360 NCCI
78258 96365 NCCI
78258 96372 NCCI
78258 96374 NCCI
78258 96375 NCCI
78258 96376 NCCI
78261 36000 NCCI
78261 36005 NCCI
78261 36410 NCCI
78261 76000 NCCI
78261 76001 NCCI
78261 76376 NCCI
78261 76377 NCCI
78261 76942 NCCI
Comprehensive ComponentCode Code Source
78261 76998 NCCI
78261 77001 NCCI
78261 77002 NCCI
78261 77750 NCCI
78261 77761 NCCI
78261 77762 NCCI
78261 77763 NCCI
78261 77776 NCCI
78261 77777 NCCI
78261 77778 NCCI
78261 77789 NCCI
78261 77790 NCCI
78261 78261 BCBST
78261 78445 NCCI
78261 96360 NCCI
78261 96365 NCCI
78261 96372 NCCI
78261 96374 NCCI
78261 96375 NCCI
78261 96376 NCCI
78261 J1642 NCCI
78262 36000 NCCI
78262 36005 NCCI
78262 36410 NCCI
78262 76000 NCCI
78262 76001 NCCI
78262 76376 NCCI
78262 76377 NCCI
78262 76942 NCCI
78262 76998 NCCI
78262 77001 NCCI
78262 77002 NCCI
78262 77750 NCCI
78262 77761 NCCI
78262 77762 NCCI
78262 77763 NCCI
78262 77776 NCCI
78262 77777 NCCI
78262 77778 NCCI
78262 77789 NCCI
78262 77790 NCCI
78262 78262 BCBST
78262 78445 NCCI
78262 96360 NCCI
78262 96365 NCCI
78262 96372 NCCI
78262 96374 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 191 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78262 96375 NCCI
78262 96376 NCCI
78264 36000 NCCI
78264 36005 NCCI
78264 36410 NCCI
78264 76000 NCCI
78264 76001 NCCI
78264 76376 NCCI
78264 76377 NCCI
78264 76942 NCCI
78264 76998 NCCI
78264 77001 NCCI
78264 77002 NCCI
78264 77750 NCCI
78264 77761 NCCI
78264 77762 NCCI
78264 77763 NCCI
78264 77776 NCCI
78264 77777 NCCI
78264 77778 NCCI
78264 77789 NCCI
78264 77790 NCCI
78264 78264 BCBST
78264 78445 NCCI
78264 96360 NCCI
78264 96365 NCCI
78264 96372 NCCI
78264 96374 NCCI
78264 96375 NCCI
78264 96376 NCCI
78267 36005 NCCI
78267 76376 NCCI
78267 76377 NCCI
78267 78267 BCBST
78267 78445 NCCI
78267 83013 NCCI
78268 36005 NCCI
78268 76376 NCCI
78268 76377 NCCI
78268 78445 NCCI
78268 83013 NCCI
78268 83014 NCCI
78268 83519 NCCI
78268 83520 NCCI
78270 36000 NCCI
78270 36005 NCCI
78270 36410 NCCI
Comprehensive ComponentCode Code Source
78270 76000 NCCI
78270 76001 NCCI
78270 76376 NCCI
78270 76377 NCCI
78270 76942 NCCI
78270 76998 NCCI
78270 77001 NCCI
78270 77002 NCCI
78270 77750 NCCI
78270 77761 NCCI
78270 77762 NCCI
78270 77763 NCCI
78270 77776 NCCI
78270 77777 NCCI
78270 77778 NCCI
78270 77789 NCCI
78270 77790 NCCI
78270 78270 BCBST
78270 78445 NCCI
78270 96360 NCCI
78270 96365 NCCI
78270 96372 NCCI
78270 96374 NCCI
78270 96375 NCCI
78270 96376 NCCI
78271 36000 NCCI
78271 36005 NCCI
78271 36410 NCCI
78271 76000 NCCI
78271 76001 NCCI
78271 76376 NCCI
78271 76377 NCCI
78271 76942 NCCI
78271 76998 NCCI
78271 77001 NCCI
78271 77002 NCCI
78271 77761 NCCI
78271 77762 NCCI
78271 77763 NCCI
78271 77776 NCCI
78271 77777 NCCI
78271 77778 NCCI
78271 77789 NCCI
78271 77790 NCCI
78271 78270 NCCI
78271 78271 BCBST
78271 78445 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 192 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78271 96360 NCCI
78271 96365 NCCI
78271 96372 NCCI
78271 96374 NCCI
78271 96375 NCCI
78271 96376 NCCI
78272 36000 NCCI
78272 36005 NCCI
78272 36410 NCCI
78272 76000 NCCI
78272 76001 NCCI
78272 76376 NCCI
78272 76377 NCCI
78272 76942 NCCI
78272 76998 NCCI
78272 77001 NCCI
78272 77002 NCCI
78272 77761 NCCI
78272 77762 NCCI
78272 77763 NCCI
78272 77776 NCCI
78272 77777 NCCI
78272 77778 NCCI
78272 77789 NCCI
78272 77790 NCCI
78272 78270 NCCI
78272 78271 NCCI
78272 78272 BCBST
78272 78445 NCCI
78272 96360 NCCI
78272 96365 NCCI
78272 96372 NCCI
78272 96374 NCCI
78272 96375 NCCI
78272 96376 NCCI
78278 36000 NCCI
78278 36005 NCCI
78278 36410 NCCI
78278 76000 NCCI
78278 76001 NCCI
78278 76376 NCCI
78278 76377 NCCI
78278 76942 NCCI
78278 76998 NCCI
78278 77001 NCCI
78278 77002 NCCI
78278 77750 NCCI
Comprehensive ComponentCode Code Source
78278 77761 NCCI
78278 77762 NCCI
78278 77763 NCCI
78278 77776 NCCI
78278 77777 NCCI
78278 77778 NCCI
78278 77789 NCCI
78278 77790 NCCI
78278 78278 BCBST
78278 78445 NCCI
78278 96360 NCCI
78278 96365 NCCI
78278 96372 NCCI
78278 96374 NCCI
78278 96375 NCCI
78278 96376 NCCI
78278 J1642 NCCI
78282 36000 NCCI
78282 36005 NCCI
78282 36410 NCCI
78282 76000 NCCI
78282 76001 NCCI
78282 76376 NCCI
78282 76377 NCCI
78282 76942 NCCI
78282 76998 NCCI
78282 77001 NCCI
78282 77002 NCCI
78282 77750 NCCI
78282 77761 NCCI
78282 77762 NCCI
78282 77763 NCCI
78282 77776 NCCI
78282 77777 NCCI
78282 77778 NCCI
78282 77789 NCCI
78282 77790 NCCI
78282 78282 BCBST
78282 78445 NCCI
78282 96360 NCCI
78282 96365 NCCI
78282 96372 NCCI
78282 96374 NCCI
78282 96375 NCCI
78282 96376 NCCI
78290 36000 NCCI
78290 36005 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 193 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78290 36410 NCCI
78290 76000 NCCI
78290 76001 NCCI
78290 76376 NCCI
78290 76377 NCCI
78290 76942 NCCI
78290 76998 NCCI
78290 77001 NCCI
78290 77002 NCCI
78290 77750 NCCI
78290 77761 NCCI
78290 77762 NCCI
78290 77763 NCCI
78290 77776 NCCI
78290 77777 NCCI
78290 77778 NCCI
78290 77789 NCCI
78290 77790 NCCI
78290 78290 BCBST
78290 78445 NCCI
78290 96360 NCCI
78290 96365 NCCI
78290 96372 NCCI
78290 96374 NCCI
78290 96375 NCCI
78290 96376 NCCI
78290 J1642 NCCI
78291 36000 NCCI
78291 36005 NCCI
78291 36410 NCCI
78291 76000 NCCI
78291 76001 NCCI
78291 76376 NCCI
78291 76377 NCCI
78291 76942 NCCI
78291 76998 NCCI
78291 77001 NCCI
78291 77002 NCCI
78291 77750 NCCI
78291 77761 NCCI
78291 77762 NCCI
78291 77763 NCCI
78291 77776 NCCI
78291 77777 NCCI
78291 77778 NCCI
78291 77789 NCCI
78291 77790 NCCI
Comprehensive ComponentCode Code Source
78291 78291 BCBST
78291 78445 NCCI
78291 96360 NCCI
78291 96365 NCCI
78291 96372 NCCI
78291 96374 NCCI
78291 96375 NCCI
78291 96376 NCCI
78291 J1642 NCCI
78300 36000 NCCI
78300 36005 NCCI
78300 36410 NCCI
78300 76000 NCCI
78300 76001 NCCI
78300 76376 NCCI
78300 76377 NCCI
78300 76942 NCCI
78300 76998 NCCI
78300 77001 NCCI
78300 77002 NCCI
78300 77750 NCCI
78300 77761 NCCI
78300 77762 NCCI
78300 77763 NCCI
78300 77776 NCCI
78300 77777 NCCI
78300 77778 NCCI
78300 77789 NCCI
78300 77790 NCCI
78300 78300 BCBST
78300 78445 NCCI
78300 96360 NCCI
78300 96365 NCCI
78300 96372 NCCI
78300 96374 NCCI
78300 96375 NCCI
78300 96376 NCCI
78300 J1642 NCCI
78305 36000 NCCI
78305 36005 NCCI
78305 36410 NCCI
78305 76000 NCCI
78305 76001 NCCI
78305 76376 NCCI
78305 76377 NCCI
78305 76942 NCCI
78305 76998 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 194 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78305 77001 NCCI
78305 77002 NCCI
78305 77750 NCCI
78305 77761 NCCI
78305 77762 NCCI
78305 77763 NCCI
78305 77776 NCCI
78305 77777 NCCI
78305 77778 NCCI
78305 77789 NCCI
78305 77790 NCCI
78305 78300 NCCI
78305 78305 BCBST
78305 78445 NCCI
78305 96360 NCCI
78305 96365 NCCI
78305 96372 NCCI
78305 96374 NCCI
78305 96375 NCCI
78305 96376 NCCI
78305 J1642 NCCI
78306 36000 NCCI
78306 36005 NCCI
78306 36410 NCCI
78306 76000 NCCI
78306 76001 NCCI
78306 76376 NCCI
78306 76377 NCCI
78306 76942 NCCI
78306 76998 NCCI
78306 77001 NCCI
78306 77002 NCCI
78306 77750 NCCI
78306 77761 NCCI
78306 77762 NCCI
78306 77763 NCCI
78306 77776 NCCI
78306 77777 NCCI
78306 77778 NCCI
78306 77789 NCCI
78306 77790 NCCI
78306 78300 NCCI
78306 78305 NCCI
78306 78306 BCBST
78306 78445 NCCI
78306 96360 NCCI
78306 96365 NCCI
Comprehensive ComponentCode Code Source
78306 96372 NCCI
78306 96374 NCCI
78306 96375 NCCI
78306 96376 NCCI
78306 J1642 NCCI
78315 36000 NCCI
78315 36005 NCCI
78315 36410 NCCI
78315 76000 NCCI
78315 76001 NCCI
78315 76376 NCCI
78315 76377 NCCI
78315 76942 NCCI
78315 76998 NCCI
78315 77001 NCCI
78315 77002 NCCI
78315 77750 NCCI
78315 77761 NCCI
78315 77762 NCCI
78315 77763 NCCI
78315 77776 NCCI
78315 77777 NCCI
78315 77778 NCCI
78315 77789 NCCI
78315 77790 NCCI
78315 78300 NCCI
78315 78305 NCCI
78315 78306 NCCI
78315 78315 BCBST
78315 78445 NCCI
78315 96360 NCCI
78315 96365 NCCI
78315 96372 NCCI
78315 96374 NCCI
78315 96375 NCCI
78315 96376 NCCI
78315 J1642 NCCI
78320 36000 NCCI
78320 36005 NCCI
78320 36410 NCCI
78320 76000 NCCI
78320 76001 NCCI
78320 76376 NCCI
78320 76377 NCCI
78320 76942 NCCI
78320 76998 NCCI
78320 77001 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 195 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78320 77002 NCCI
78320 77750 NCCI
78320 77761 NCCI
78320 77762 NCCI
78320 77763 NCCI
78320 77776 NCCI
78320 77777 NCCI
78320 77778 NCCI
78320 77789 NCCI
78320 77790 NCCI
78320 78300 NCCI
78320 78305 NCCI
78320 78315 NCCI
78320 78320 CPT
78320 78445 NCCI
78320 96360 NCCI
78320 96365 NCCI
78320 96372 NCCI
78320 96374 NCCI
78320 96375 NCCI
78320 96376 NCCI
78320 J1642 NCCI
78350 78350 CPT
78351 78351 CPT
78414 36000 NCCI
78414 36005 NCCI
78414 36410 NCCI
78414 76000 NCCI
78414 76001 NCCI
78414 76376 NCCI
78414 76377 NCCI
78414 76942 NCCI
78414 76998 NCCI
78414 77001 NCCI
78414 77002 NCCI
78414 77750 NCCI
78414 77761 NCCI
78414 77762 NCCI
78414 77763 NCCI
78414 77776 NCCI
78414 77777 NCCI
78414 77778 NCCI
78414 77789 NCCI
78414 77790 NCCI
78414 78414 CPT
78414 78445 NCCI
78414 96360 NCCI
Comprehensive ComponentCode Code Source
78414 96365 NCCI
78414 96372 NCCI
78414 96374 NCCI
78414 96375 NCCI
78414 96376 NCCI
78414 J1642 NCCI
78428 36000 NCCI
78428 36005 NCCI
78428 36410 NCCI
78428 76000 NCCI
78428 76001 NCCI
78428 76376 NCCI
78428 76377 NCCI
78428 76942 NCCI
78428 76998 NCCI
78428 77001 NCCI
78428 77002 NCCI
78428 77750 NCCI
78428 77761 NCCI
78428 77762 NCCI
78428 77763 NCCI
78428 77776 NCCI
78428 77777 NCCI
78428 77778 NCCI
78428 77789 NCCI
78428 77790 NCCI
78428 78428 BCBST
78428 78445 NCCI
78428 96360 NCCI
78428 96365 NCCI
78428 96372 NCCI
78428 96374 NCCI
78428 96375 NCCI
78428 96376 NCCI
78428 J1642 NCCI
78445 36000 NCCI
78445 36005 NCCI
78445 36410 NCCI
78445 75820 NCCI
78445 75822 NCCI
78445 75825 NCCI
78445 75827 NCCI
78445 75831 NCCI
78445 75833 NCCI
78445 75840 NCCI
78445 75842 NCCI
78445 75860 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 196 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78445 75870 NCCI
78445 75872 NCCI
78445 75880 NCCI
78445 75885 NCCI
78445 75887 NCCI
78445 75889 NCCI
78445 75891 NCCI
78445 76000 NCCI
78445 76001 NCCI
78445 76376 NCCI
78445 76377 NCCI
78445 76942 NCCI
78445 76998 NCCI
78445 77001 NCCI
78445 77002 NCCI
78445 77750 NCCI
78445 77761 NCCI
78445 77762 NCCI
78445 77763 NCCI
78445 77776 NCCI
78445 77777 NCCI
78445 77778 NCCI
78445 77789 NCCI
78445 77790 NCCI
78445 78445 BCBST
78445 96360 NCCI
78445 96365 NCCI
78445 96372 NCCI
78445 96374 NCCI
78445 96375 NCCI
78445 96376 NCCI
78445 J1642 NCCI
78451 36000 NCCI
78451 36005 NCCI
78451 36410 NCCI
78451 76000 NCCI
78451 76001 NCCI
78451 76376 NCCI
78451 76377 NCCI
78451 76942 NCCI
78451 76998 NCCI
78451 77001 NCCI
78451 77002 NCCI
78451 78445 NCCI
78451 78453 NCCI
78451 78454 NCCI
78451 78472 NCCI
Comprehensive ComponentCode Code Source
78451 78473 NCCI
78451 78481 NCCI
78451 78483 NCCI
78451 78494 NCCI
78451 78496 NCCI
78451 78580 NCCI
78451 78582 NCCI
78451 78597 NCCI
78451 78598 NCCI
78451 78635 NCCI
78451 96360 NCCI
78451 96365 NCCI
78451 96372 NCCI
78451 96374 NCCI
78451 96375 NCCI
78451 96376 NCCI
78451 J1642 NCCI
78452 36000 NCCI
78452 36005 NCCI
78452 36410 NCCI
78452 76000 NCCI
78452 76001 NCCI
78452 76376 NCCI
78452 76377 NCCI
78452 76942 NCCI
78452 76998 NCCI
78452 77001 NCCI
78452 77002 NCCI
78452 78445 NCCI
78452 78451 NCCI
78452 78453 NCCI
78452 78454 NCCI
78452 78472 NCCI
78452 78473 NCCI
78452 78481 NCCI
78452 78483 NCCI
78452 78494 NCCI
78452 78496 NCCI
78452 78580 NCCI
78452 78582 NCCI
78452 78597 NCCI
78452 78598 NCCI
78452 78635 NCCI
78452 96360 NCCI
78452 96365 NCCI
78452 96372 NCCI
78452 96374 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 197 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78452 96375 NCCI
78452 96376 NCCI
78452 J1642 NCCI
78453 36000 NCCI
78453 36005 NCCI
78453 36410 NCCI
78453 76000 NCCI
78453 76001 NCCI
78453 76376 NCCI
78453 76377 NCCI
78453 76942 NCCI
78453 76998 NCCI
78453 77001 NCCI
78453 77002 NCCI
78453 78445 NCCI
78453 78472 NCCI
78453 78473 NCCI
78453 78481 NCCI
78453 78483 NCCI
78453 78496 NCCI
78453 78580 NCCI
78453 78582 NCCI
78453 78597 NCCI
78453 78598 NCCI
78453 78635 NCCI
78453 96360 NCCI
78453 96365 NCCI
78453 96372 NCCI
78453 96374 NCCI
78453 96375 NCCI
78453 96376 NCCI
78453 J1642 NCCI
78454 36000 NCCI
78454 36005 NCCI
78454 36410 NCCI
78454 76000 NCCI
78454 76001 NCCI
78454 76376 NCCI
78454 76377 NCCI
78454 76942 NCCI
78454 76998 NCCI
78454 77001 NCCI
78454 77002 NCCI
78454 78445 NCCI
78454 78453 NCCI
78454 78472 NCCI
78454 78473 NCCI
Comprehensive ComponentCode Code Source
78454 78481 NCCI
78454 78483 NCCI
78454 78496 NCCI
78454 78580 NCCI
78454 78582 NCCI
78454 78597 NCCI
78454 78598 NCCI
78454 78635 NCCI
78454 96360 NCCI
78454 96365 NCCI
78454 96372 NCCI
78454 96374 NCCI
78454 96375 NCCI
78454 96376 NCCI
78454 J1642 NCCI
78456 36000 NCCI
78456 36005 NCCI
78456 36410 NCCI
78456 75822 NCCI
78456 75825 NCCI
78456 75827 NCCI
78456 75831 NCCI
78456 75833 NCCI
78456 75840 NCCI
78456 75842 NCCI
78456 75860 NCCI
78456 75870 NCCI
78456 75872 NCCI
78456 75885 NCCI
78456 75887 NCCI
78456 75889 NCCI
78456 75891 NCCI
78456 76000 NCCI
78456 76001 NCCI
78456 76376 NCCI
78456 76377 NCCI
78456 76942 NCCI
78456 76998 NCCI
78456 77001 NCCI
78456 77002 NCCI
78456 78445 NCCI
78456 78456 BCBST
78456 96360 NCCI
78456 96365 NCCI
78456 96372 NCCI
78456 96374 NCCI
78456 96375 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 198 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78456 96376 NCCI
78456 J1642 NCCI
78457 36000 NCCI
78457 36005 NCCI
78457 36410 NCCI
78457 75822 NCCI
78457 75825 NCCI
78457 75827 NCCI
78457 75831 NCCI
78457 75833 NCCI
78457 75840 NCCI
78457 75842 NCCI
78457 75860 NCCI
78457 75870 NCCI
78457 75872 NCCI
78457 75885 NCCI
78457 75887 NCCI
78457 75889 NCCI
78457 75891 NCCI
78457 76000 NCCI
78457 76001 NCCI
78457 76376 NCCI
78457 76377 NCCI
78457 76942 NCCI
78457 76998 NCCI
78457 77001 NCCI
78457 77002 NCCI
78457 77750 NCCI
78457 77761 NCCI
78457 77762 NCCI
78457 77763 NCCI
78457 77776 NCCI
78457 77777 NCCI
78457 77778 NCCI
78457 77789 NCCI
78457 77790 NCCI
78457 78445 NCCI
78457 78456 NCCI
78457 96360 NCCI
78457 96365 NCCI
78457 96372 NCCI
78457 96374 NCCI
78457 96375 NCCI
78457 96376 NCCI
78457 J1642 NCCI
78458 36000 NCCI
78458 36005 NCCI
Comprehensive ComponentCode Code Source
78458 36410 NCCI
78458 75822 NCCI
78458 75825 NCCI
78458 75827 NCCI
78458 75831 NCCI
78458 75833 NCCI
78458 75840 NCCI
78458 75842 NCCI
78458 75860 NCCI
78458 75870 NCCI
78458 75872 NCCI
78458 75885 NCCI
78458 75887 NCCI
78458 75889 NCCI
78458 75891 NCCI
78458 76000 NCCI
78458 76001 NCCI
78458 76376 NCCI
78458 76377 NCCI
78458 76942 NCCI
78458 76998 NCCI
78458 77001 NCCI
78458 77002 NCCI
78458 77750 NCCI
78458 77761 NCCI
78458 77762 NCCI
78458 77763 NCCI
78458 77776 NCCI
78458 77777 NCCI
78458 77778 NCCI
78458 77789 NCCI
78458 77790 NCCI
78458 78445 NCCI
78458 78456 NCCI
78458 78457 NCCI
78458 78458 CPT
78458 96360 NCCI
78458 96365 NCCI
78458 96372 NCCI
78458 96374 NCCI
78458 96375 NCCI
78458 96376 NCCI
78458 J1642 NCCI
78459 36000 NCCI
78459 36005 NCCI
78459 36410 NCCI
78459 76376 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 199 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78459 76377 NCCI
78459 78445 NCCI
78459 78459 BCBST
78459 96360 NCCI
78459 96365 NCCI
78459 96372 NCCI
78459 96374 NCCI
78459 96375 NCCI
78459 96376 NCCI
78459 A4641 NCCI
78466 36000 NCCI
78466 36005 NCCI
78466 36410 NCCI
78466 76000 NCCI
78466 76001 NCCI
78466 76376 NCCI
78466 76377 NCCI
78466 76942 NCCI
78466 76998 NCCI
78466 77001 NCCI
78466 77002 NCCI
78466 77750 NCCI
78466 77761 NCCI
78466 77762 NCCI
78466 77763 NCCI
78466 77776 NCCI
78466 77777 NCCI
78466 77778 NCCI
78466 77789 NCCI
78466 77790 NCCI
78466 78445 NCCI
78466 78466 BCBST
78466 78468 NCCI
78466 78469 NCCI
78466 78635 NCCI
78466 96360 NCCI
78466 96365 NCCI
78466 96372 NCCI
78466 96374 NCCI
78466 96375 NCCI
78466 96376 NCCI
78466 J1642 NCCI
78468 36000 NCCI
78468 36005 NCCI
78468 36410 NCCI
78468 76000 NCCI
78468 76001 NCCI
Comprehensive ComponentCode Code Source
78468 76376 NCCI
78468 76377 NCCI
78468 76942 NCCI
78468 76998 NCCI
78468 77001 NCCI
78468 77002 NCCI
78468 77750 NCCI
78468 77761 NCCI
78468 77762 NCCI
78468 77763 NCCI
78468 77776 NCCI
78468 77777 NCCI
78468 77778 NCCI
78468 77789 NCCI
78468 77790 NCCI
78468 78445 NCCI
78468 78468 BCBST
78468 78635 NCCI
78468 96360 NCCI
78468 96365 NCCI
78468 96372 NCCI
78468 96374 NCCI
78468 96375 NCCI
78468 96376 NCCI
78468 J1642 NCCI
78469 36000 NCCI
78469 36005 NCCI
78469 36410 NCCI
78469 76000 NCCI
78469 76001 NCCI
78469 76376 NCCI
78469 76377 NCCI
78469 76942 NCCI
78469 76998 NCCI
78469 77001 NCCI
78469 77002 NCCI
78469 77750 NCCI
78469 77761 NCCI
78469 77762 NCCI
78469 77763 NCCI
78469 77776 NCCI
78469 77777 NCCI
78469 77778 NCCI
78469 77789 NCCI
78469 77790 NCCI
78469 78445 NCCI
78469 78468 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 200 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78469 78469 BCBST
78469 78635 NCCI
78469 96360 NCCI
78469 96365 NCCI
78469 96372 NCCI
78469 96374 NCCI
78469 96375 NCCI
78469 96376 NCCI
78469 J1642 NCCI
78472 36000 NCCI
78472 36005 NCCI
78472 36410 NCCI
78472 76000 NCCI
78472 76001 NCCI
78472 76376 NCCI
78472 76377 NCCI
78472 76942 NCCI
78472 76998 NCCI
78472 77001 NCCI
78472 77002 NCCI
78472 77750 NCCI
78472 77761 NCCI
78472 77762 NCCI
78472 77763 NCCI
78472 77776 NCCI
78472 77777 NCCI
78472 77778 NCCI
78472 77789 NCCI
78472 77790 NCCI
78472 78445 NCCI
78472 78472 BCBST
78472 78481 NCCI
78472 78635 NCCI
78472 96360 NCCI
78472 96365 NCCI
78472 96372 NCCI
78472 96374 NCCI
78472 96375 NCCI
78472 96376 NCCI
78472 J1642 NCCI
78473 36000 NCCI
78473 36005 NCCI
78473 36410 NCCI
78473 76000 NCCI
78473 76001 NCCI
78473 76376 NCCI
78473 76377 NCCI
Comprehensive ComponentCode Code Source
78473 76942 NCCI
78473 76998 NCCI
78473 77001 NCCI
78473 77002 NCCI
78473 77750 NCCI
78473 77761 NCCI
78473 77762 NCCI
78473 77763 NCCI
78473 77776 NCCI
78473 77777 NCCI
78473 77778 NCCI
78473 77789 NCCI
78473 77790 NCCI
78473 78445 NCCI
78473 78472 NCCI
78473 78473 BCBST
78473 78481 NCCI
78473 78483 NCCI
78473 78483 NCCI
78473 78494 NCCI
78473 78496 NCCI
78473 78635 NCCI
78473 96360 NCCI
78473 96365 NCCI
78473 96372 NCCI
78473 96374 NCCI
78473 96375 NCCI
78473 96376 NCCI
78473 J1642 NCCI
78481 36000 NCCI
78481 36005 NCCI
78481 36410 NCCI
78481 76000 NCCI
78481 76001 NCCI
78481 76376 NCCI
78481 76377 NCCI
78481 76942 NCCI
78481 76998 NCCI
78481 77001 NCCI
78481 77002 NCCI
78481 77750 NCCI
78481 77761 NCCI
78481 77762 NCCI
78481 77763 NCCI
78481 77776 NCCI
78481 77777 NCCI
78481 77778 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 201 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78481 77789 NCCI
78481 77790 NCCI
78481 78445 NCCI
78481 78496 NCCI
78481 78635 NCCI
78481 96360 NCCI
78481 96365 NCCI
78481 96372 NCCI
78481 96374 NCCI
78481 96375 NCCI
78481 96376 NCCI
78481 J1642 NCCI
78483 36000 NCCI
78483 36005 NCCI
78483 36410 NCCI
78483 76000 NCCI
78483 76001 NCCI
78483 76376 NCCI
78483 76377 NCCI
78483 76942 NCCI
78483 76998 NCCI
78483 77001 NCCI
78483 77002 NCCI
78483 77750 NCCI
78483 77761 NCCI
78483 77762 NCCI
78483 77763 NCCI
78483 77776 NCCI
78483 77777 NCCI
78483 77778 NCCI
78483 77789 NCCI
78483 77790 NCCI
78483 78445 NCCI
78483 78472 NCCI
78483 78481 NCCI
78483 78483 BCBST
78483 78494 NCCI
78483 78496 NCCI
78483 78635 NCCI
78483 96360 NCCI
78483 96365 NCCI
78483 96372 NCCI
78483 96374 NCCI
78483 96375 NCCI
78483 96376 NCCI
78483 J1642 NCCI
78491 36000 NCCI
Comprehensive ComponentCode Code Source
78491 36005 NCCI
78491 36410 NCCI
78491 76376 NCCI
78491 76377 NCCI
78491 78445 NCCI
78491 96360 NCCI
78491 96365 NCCI
78491 96372 NCCI
78491 96374 NCCI
78491 96375 NCCI
78491 96376 NCCI
78491 A4641 NCCI
78492 36000 NCCI
78492 36005 NCCI
78492 36410 NCCI
78492 76376 NCCI
78492 76377 NCCI
78492 78445 NCCI
78492 78491 NCCI
78492 78491 BCBST
78492 96360 NCCI
78492 96365 NCCI
78492 96372 NCCI
78492 96374 NCCI
78492 96375 NCCI
78492 96376 NCCI
78492 A4641 NCCI
78494 36000 NCCI
78494 36005 NCCI
78494 36410 NCCI
78494 76000 NCCI
78494 76001 NCCI
78494 76376 NCCI
78494 76377 NCCI
78494 76942 NCCI
78494 76998 NCCI
78494 77001 NCCI
78494 77002 NCCI
78494 78445 NCCI
78494 78481 NCCI
78494 78496 NCCI
78494 78635 NCCI
78494 96360 NCCI
78494 96365 NCCI
78494 96372 NCCI
78494 96374 NCCI
78494 96375 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 202 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78494 96376 NCCI
78494 J1642 NCCI
78496 36000 NCCI
78496 36005 NCCI
78496 36410 NCCI
78496 78445 NCCI
78579 36000 NCCI
78579 36005 NCCI
78579 36410 NCCI
78579 76000 NCCI
78579 76001 NCCI
78579 76376 NCCI
78579 76377 NCCI
78579 76942 NCCI
78579 76998 NCCI
78579 77001 NCCI
78579 77002 NCCI
78579 78445 NCCI
78579 96360 NCCI
78579 96365 NCCI
78579 96372 NCCI
78579 96374 NCCI
78579 96375 NCCI
78579 96376 NCCI
78579 J1642 NCCI
78580 36000 NCCI
78580 36005 NCCI
78580 36410 NCCI
78580 76000 NCCI
78580 76001 NCCI
78580 76376 NCCI
78580 76377 NCCI
78580 76942 NCCI
78580 76998 NCCI
78580 77001 NCCI
78580 77002 NCCI
78580 77750 NCCI
78580 77761 NCCI
78580 77762 NCCI
78580 77763 NCCI
78580 77776 NCCI
78580 77777 NCCI
78580 77778 NCCI
78580 77789 NCCI
78580 77790 NCCI
78580 78445 NCCI
78580 78580 BCBST
Comprehensive ComponentCode Code Source
78580 96360 NCCI
78580 96365 NCCI
78580 96372 NCCI
78580 96374 NCCI
78580 96375 NCCI
78580 96376 NCCI
78580 J1642 NCCI
78582 36000 NCCI
78582 36005 NCCI
78582 36410 NCCI
78582 76000 NCCI
78582 76001 NCCI
78582 76376 NCCI
78582 76377 NCCI
78582 76942 NCCI
78582 76998 NCCI
78582 77001 NCCI
78582 77002 NCCI
78582 78445 NCCI
78582 78579 NCCI
78582 78580 NCCI
78582 78598 NCCI
78582 96360 NCCI
78582 96365 NCCI
78582 96372 NCCI
78582 96374 NCCI
78582 96375 NCCI
78582 96376 NCCI
78582 J1642 NCCI
78597 36000 NCCI
78597 36005 NCCI
78597 36410 NCCI
78597 76000 NCCI
78597 76001 NCCI
78597 76376 NCCI
78597 76377 NCCI
78597 76942 NCCI
78597 76998 NCCI
78597 77001 NCCI
78597 77002 NCCI
78597 78445 NCCI
78597 78579 NCCI
78597 78580 NCCI
78597 78582 NCCI
78597 96360 NCCI
78597 96365 NCCI
78597 96372 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 203 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78597 96374 NCCI
78597 96375 NCCI
78597 96376 NCCI
78597 J1642 NCCI
78598 36000 NCCI
78598 36005 NCCI
78598 36410 NCCI
78598 76000 NCCI
78598 76001 NCCI
78598 76376 NCCI
78598 76377 NCCI
78598 76942 NCCI
78598 76998 NCCI
78598 77001 NCCI
78598 77002 NCCI
78598 78445 NCCI
78598 78579 NCCI
78598 78580 NCCI
78598 78597 NCCI
78598 96360 NCCI
78598 96365 NCCI
78598 96372 NCCI
78598 96374 NCCI
78598 96375 NCCI
78598 96376 NCCI
78598 J1642 NCCI
78600 36000 NCCI
78600 36005 NCCI
78600 36410 NCCI
78600 76000 NCCI
78600 76001 NCCI
78600 76376 NCCI
78600 76377 NCCI
78600 76942 NCCI
78600 76998 NCCI
78600 77001 NCCI
78600 77002 NCCI
78600 77750 NCCI
78600 77761 NCCI
78600 77762 NCCI
78600 77763 NCCI
78600 77776 NCCI
78600 77777 NCCI
78600 77778 NCCI
78600 77789 NCCI
78600 77790 NCCI
78600 78445 NCCI
Comprehensive ComponentCode Code Source
78600 78600 CPT
78600 96360 NCCI
78600 96365 NCCI
78600 96372 NCCI
78600 96374 NCCI
78600 96375 NCCI
78600 96376 NCCI
78601 36000 NCCI
78601 36005 NCCI
78601 36410 NCCI
78601 76000 NCCI
78601 76001 NCCI
78601 76376 NCCI
78601 76377 NCCI
78601 76942 NCCI
78601 76998 NCCI
78601 77001 NCCI
78601 77002 NCCI
78601 77750 NCCI
78601 77761 NCCI
78601 77762 NCCI
78601 77763 NCCI
78601 77776 NCCI
78601 77777 NCCI
78601 77778 NCCI
78601 77789 NCCI
78601 77790 NCCI
78601 78445 NCCI
78601 78600 NCCI
78601 78601 CPT
78601 78610 NCCI
78601 96360 NCCI
78601 96365 NCCI
78601 96372 NCCI
78601 96374 NCCI
78601 96375 NCCI
78601 96376 NCCI
78601 J1642 NCCI
78605 36000 NCCI
78605 36005 NCCI
78605 36410 NCCI
78605 76000 NCCI
78605 76001 NCCI
78605 76376 NCCI
78605 76377 NCCI
78605 76942 NCCI
78605 76998 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 204 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78605 77001 NCCI
78605 77002 NCCI
78605 77750 NCCI
78605 77762 NCCI
78605 77763 NCCI
78605 77776 NCCI
78605 77777 NCCI
78605 77778 NCCI
78605 77789 NCCI
78605 77790 NCCI
78605 78445 NCCI
78605 78600 NCCI
78605 78605 CPT
78605 96360 NCCI
78605 96365 NCCI
78605 96372 NCCI
78605 96374 NCCI
78605 96375 NCCI
78605 96376 NCCI
78606 36000 NCCI
78606 36005 NCCI
78606 36410 NCCI
78606 76000 NCCI
78606 76001 NCCI
78606 76376 NCCI
78606 76377 NCCI
78606 76942 NCCI
78606 76998 NCCI
78606 77001 NCCI
78606 77002 NCCI
78606 77750 NCCI
78606 77761 NCCI
78606 77762 NCCI
78606 77763 NCCI
78606 77776 NCCI
78606 77777 NCCI
78606 77778 NCCI
78606 77789 NCCI
78606 77790 NCCI
78606 78445 NCCI
78606 78600 NCCI
78606 78601 NCCI
78606 78605 NCCI
78606 78606 CPT
78606 78610 NCCI
78606 96360 NCCI
78606 96365 NCCI
Comprehensive ComponentCode Code Source
78606 96372 NCCI
78606 96374 NCCI
78606 96375 NCCI
78606 96376 NCCI
78606 J1642 NCCI
78607 36000 NCCI
78607 36005 NCCI
78607 36410 NCCI
78607 76000 NCCI
78607 76001 NCCI
78607 76376 NCCI
78607 76377 NCCI
78607 76942 NCCI
78607 76998 NCCI
78607 77001 NCCI
78607 77002 NCCI
78607 77750 NCCI
78607 77761 NCCI
78607 77762 NCCI
78607 77763 NCCI
78607 77776 NCCI
78607 77777 NCCI
78607 77778 NCCI
78607 77789 NCCI
78607 77790 NCCI
78607 78445 NCCI
78607 78600 NCCI
78607 78601 NCCI
78607 78605 NCCI
78607 78606 NCCI
78607 78607 CPT
78607 96360 NCCI
78607 96365 NCCI
78607 96372 NCCI
78607 96374 NCCI
78607 96375 NCCI
78607 96376 NCCI
78608 36000 NCCI
78608 36005 NCCI
78608 36410 NCCI
78608 76376 NCCI
78608 76377 NCCI
78608 78608 CPT
78608 96360 NCCI
78608 96365 NCCI
78608 96372 NCCI
78608 96374 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 205 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78608 96375 NCCI
78608 96376 NCCI
78608 A4641 NCCI
78608 A9526 NCCI
78608 A9555 NCCI
78609 78609 CPT
78610 36000 NCCI
78610 36005 NCCI
78610 36410 NCCI
78610 76000 NCCI
78610 76001 NCCI
78610 76376 NCCI
78610 76377 NCCI
78610 76942 NCCI
78610 76998 NCCI
78610 77001 NCCI
78610 77002 NCCI
78610 77750 NCCI
78610 77761 NCCI
78610 77762 NCCI
78610 77763 NCCI
78610 77776 NCCI
78610 77777 NCCI
78610 77778 NCCI
78610 77789 NCCI
78610 77790 NCCI
78610 78445 NCCI
78610 78610 CPT
78610 96360 NCCI
78610 96365 NCCI
78610 96372 NCCI
78610 96374 NCCI
78610 96375 NCCI
78610 96376 NCCI
78610 J1642 NCCI
78630 36000 NCCI
78630 36005 NCCI
78630 36410 NCCI
78630 76000 NCCI
78630 76001 NCCI
78630 76376 NCCI
78630 76377 NCCI
78630 76800 NCCI
78630 76942 NCCI
78630 76998 NCCI
78630 77001 NCCI
78630 77002 NCCI
Comprehensive ComponentCode Code Source
78630 77003 NCCI
78630 77750 NCCI
78630 77761 NCCI
78630 77762 NCCI
78630 77763 NCCI
78630 77776 NCCI
78630 77777 NCCI
78630 77778 NCCI
78630 77789 NCCI
78630 77790 NCCI
78630 78445 NCCI
78630 78630 BCBST
78630 78647 NCCI
78630 96360 NCCI
78630 96365 NCCI
78630 96372 NCCI
78630 96374 NCCI
78630 96375 NCCI
78630 96376 NCCI
78630 J1642 NCCI
78635 36000 NCCI
78635 36005 NCCI
78635 36410 NCCI
78635 76000 NCCI
78635 76001 NCCI
78635 76376 NCCI
78635 76377 NCCI
78635 76800 NCCI
78635 76942 NCCI
78635 76998 NCCI
78635 77001 NCCI
78635 77002 NCCI
78635 77003 NCCI
78635 77750 NCCI
78635 77761 NCCI
78635 77762 NCCI
78635 77763 NCCI
78635 77776 NCCI
78635 77777 NCCI
78635 77778 NCCI
78635 77789 NCCI
78635 77790 NCCI
78635 78445 NCCI
78635 78630 NCCI
78635 78635 BCBST
78635 78647 NCCI
78635 96360 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 206 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78635 96365 NCCI
78635 96372 NCCI
78635 96374 NCCI
78635 96375 NCCI
78635 96376 NCCI
78635 J1642 NCCI
78645 36000 NCCI
78645 36005 NCCI
78645 36410 NCCI
78645 76000 NCCI
78645 76001 NCCI
78645 76376 NCCI
78645 76377 NCCI
78645 76800 NCCI
78645 76942 NCCI
78645 76998 NCCI
78645 77001 NCCI
78645 77002 NCCI
78645 77750 NCCI
78645 77761 NCCI
78645 77762 NCCI
78645 77763 NCCI
78645 77776 NCCI
78645 77777 NCCI
78645 77778 NCCI
78645 77789 NCCI
78645 77790 NCCI
78645 78445 NCCI
78645 78630 NCCI
78645 78635 NCCI
78645 78645 BCBST
78645 78647 NCCI
78645 78650 NCCI
78645 96360 NCCI
78645 96365 NCCI
78645 96372 NCCI
78645 96374 NCCI
78645 96375 NCCI
78645 96376 NCCI
78645 J1642 NCCI
78647 36000 NCCI
78647 36005 NCCI
78647 36410 NCCI
78647 76000 NCCI
78647 76001 NCCI
78647 76376 NCCI
78647 76377 NCCI
Comprehensive ComponentCode Code Source
78647 76800 NCCI
78647 76942 NCCI
78647 76998 NCCI
78647 77001 NCCI
78647 77002 NCCI
78647 77003 NCCI
78647 77750 NCCI
78647 77761 NCCI
78647 77762 NCCI
78647 77763 NCCI
78647 77776 NCCI
78647 77777 NCCI
78647 77778 NCCI
78647 77789 NCCI
78647 77790 NCCI
78647 78445 NCCI
78647 78647 BCBST
78647 96360 NCCI
78647 96365 NCCI
78647 96372 NCCI
78647 96374 NCCI
78647 96375 NCCI
78647 96376 NCCI
78650 36000 NCCI
78650 36005 NCCI
78650 36410 NCCI
78650 76000 NCCI
78650 76001 NCCI
78650 76376 NCCI
78650 76377 NCCI
78650 76800 NCCI
78650 76942 NCCI
78650 76998 NCCI
78650 77001 NCCI
78650 77002 NCCI
78650 77003 NCCI
78650 77750 NCCI
78650 77761 NCCI
78650 77762 NCCI
78650 77763 NCCI
78650 77776 NCCI
78650 77777 NCCI
78650 77778 NCCI
78650 77789 NCCI
78650 77790 NCCI
78650 78445 NCCI
78650 78630 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 207 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78650 78635 NCCI
78650 78647 NCCI
78650 78650 BCBST
78650 96360 NCCI
78650 96365 NCCI
78650 96372 NCCI
78650 96374 NCCI
78650 96375 NCCI
78650 96376 NCCI
78650 J1642 NCCI
78660 36000 NCCI
78660 36005 NCCI
78660 36410 NCCI
78660 76000 NCCI
78660 76001 NCCI
78660 76376 NCCI
78660 76377 NCCI
78660 76942 NCCI
78660 76998 NCCI
78660 77001 NCCI
78660 77002 NCCI
78660 77750 NCCI
78660 77761 NCCI
78660 77762 NCCI
78660 77763 NCCI
78660 77776 NCCI
78660 77777 NCCI
78660 77778 NCCI
78660 77789 NCCI
78660 77790 NCCI
78660 78445 NCCI
78660 78660 BCBST
78660 96360 NCCI
78660 96365 NCCI
78660 96372 NCCI
78660 96374 NCCI
78660 96375 NCCI
78660 96376 NCCI
78660 J1642 NCCI
78700 36000 NCCI
78700 36005 NCCI
78700 36410 NCCI
78700 76000 NCCI
78700 76001 NCCI
78700 76376 NCCI
78700 76377 NCCI
78700 76942 NCCI
Comprehensive ComponentCode Code Source
78700 76998 NCCI
78700 77001 NCCI
78700 77002 NCCI
78700 77750 NCCI
78700 77761 NCCI
78700 77762 NCCI
78700 77763 NCCI
78700 77776 NCCI
78700 77777 NCCI
78700 77778 NCCI
78700 77789 NCCI
78700 77790 NCCI
78700 78445 NCCI
78700 78725 NCCI
78700 96360 NCCI
78700 96365 NCCI
78700 96372 NCCI
78700 96374 NCCI
78700 96375 NCCI
78700 96376 NCCI
78700 J1642 NCCI
78701 36000 NCCI
78701 36005 NCCI
78701 36410 NCCI
78701 76000 NCCI
78701 76001 NCCI
78701 76376 NCCI
78701 76377 NCCI
78701 76942 NCCI
78701 76998 NCCI
78701 77001 NCCI
78701 77002 NCCI
78701 77750 NCCI
78701 77761 NCCI
78701 77762 NCCI
78701 77763 NCCI
78701 77776 NCCI
78701 77777 NCCI
78701 77778 NCCI
78701 77789 NCCI
78701 77790 NCCI
78701 78445 NCCI
78701 78700 NCCI
78701 78710 NCCI
78701 78725 NCCI
78701 96360 NCCI
78701 96365 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 208 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78701 96372 NCCI
78701 96374 NCCI
78701 96375 NCCI
78701 96376 NCCI
78701 J1642 NCCI
78707 36000 NCCI
78707 36005 NCCI
78707 36410 NCCI
78707 76000 NCCI
78707 76001 NCCI
78707 76376 NCCI
78707 76377 NCCI
78707 76942 NCCI
78707 76998 NCCI
78707 77001 NCCI
78707 77002 NCCI
78707 77750 NCCI
78707 77761 NCCI
78707 77762 NCCI
78707 77763 NCCI
78707 77776 NCCI
78707 77777 NCCI
78707 77778 NCCI
78707 77789 NCCI
78707 77790 NCCI
78707 78445 NCCI
78707 78700 NCCI
78707 78701 NCCI
78707 78708 NCCI
78707 78710 NCCI
78707 78725 NCCI
78707 96360 NCCI
78707 96365 NCCI
78707 96372 NCCI
78707 96374 NCCI
78707 96375 NCCI
78707 96376 NCCI
78708 36000 NCCI
78708 36005 NCCI
78708 36410 NCCI
78708 76000 NCCI
78708 76001 NCCI
78708 76376 NCCI
78708 76377 NCCI
78708 76942 NCCI
78708 76998 NCCI
78708 77001 NCCI
Comprehensive ComponentCode Code Source
78708 77002 NCCI
78708 78445 NCCI
78708 78700 NCCI
78708 78701 NCCI
78708 78725 NCCI
78708 96360 NCCI
78708 96365 NCCI
78708 96372 NCCI
78708 96374 NCCI
78708 96375 NCCI
78708 96376 NCCI
78708 J1642 NCCI
78709 36000 NCCI
78709 36005 NCCI
78709 36410 NCCI
78709 76000 NCCI
78709 76001 NCCI
78709 76376 NCCI
78709 76377 NCCI
78709 76942 NCCI
78709 76998 NCCI
78709 77001 NCCI
78709 77002 NCCI
78709 78445 NCCI
78709 78700 NCCI
78709 78701 NCCI
78709 78707 NCCI
78709 78708 NCCI
78709 78710 NCCI
78709 78725 NCCI
78709 96360 NCCI
78709 96365 NCCI
78709 96372 NCCI
78709 96374 NCCI
78709 96375 NCCI
78709 96376 NCCI
78709 J1642 NCCI
78710 36000 NCCI
78710 36005 NCCI
78710 36410 NCCI
78710 76000 NCCI
78710 76001 NCCI
78710 76376 NCCI
78710 76377 NCCI
78710 76942 NCCI
78710 76998 NCCI
78710 77001 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 209 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78710 77002 NCCI
78710 77750 NCCI
78710 77761 NCCI
78710 77762 NCCI
78710 77763 NCCI
78710 77776 NCCI
78710 77777 NCCI
78710 77778 NCCI
78710 77789 NCCI
78710 77790 NCCI
78710 78445 NCCI
78710 78700 NCCI
78710 78708 NCCI
78710 78725 NCCI
78710 96360 NCCI
78710 96365 NCCI
78710 96372 NCCI
78710 96374 NCCI
78710 96375 NCCI
78710 96376 NCCI
78710 J1642 NCCI
78725 36000 NCCI
78725 36005 NCCI
78725 36410 NCCI
78725 76000 NCCI
78725 76001 NCCI
78725 76376 NCCI
78725 76377 NCCI
78725 76942 NCCI
78725 76998 NCCI
78725 77001 NCCI
78725 77002 NCCI
78725 77750 NCCI
78725 77761 NCCI
78725 77762 NCCI
78725 77763 NCCI
78725 77776 NCCI
78725 77777 NCCI
78725 77778 NCCI
78725 77789 NCCI
78725 77790 NCCI
78725 78445 NCCI
78725 78725 BCBST
78725 96360 NCCI
78725 96365 NCCI
78725 96372 NCCI
78725 96374 NCCI
Comprehensive ComponentCode Code Source
78725 96375 NCCI
78725 96376 NCCI
78730 78445 NCCI
78730 78730 CPT
78740 36000 NCCI
78740 36005 NCCI
78740 36011 NCCI
78740 36406 NCCI
78740 36410 NCCI
78740 76000 NCCI
78740 76001 NCCI
78740 76376 NCCI
78740 76377 NCCI
78740 76942 NCCI
78740 76998 NCCI
78740 77001 NCCI
78740 77002 NCCI
78740 77750 NCCI
78740 77761 NCCI
78740 77762 NCCI
78740 77763 NCCI
78740 77776 NCCI
78740 77777 NCCI
78740 77778 NCCI
78740 77789 NCCI
78740 77790 NCCI
78740 78445 NCCI
78740 78740 BCBST
78740 96360 NCCI
78740 96365 NCCI
78740 96372 NCCI
78740 96374 NCCI
78740 96375 NCCI
78740 96376 NCCI
78740 J1642 NCCI
78761 36000 NCCI
78761 36005 NCCI
78761 36410 NCCI
78761 76000 NCCI
78761 76001 NCCI
78761 76376 NCCI
78761 76377 NCCI
78761 76942 NCCI
78761 76998 NCCI
78761 77001 NCCI
78761 77002 NCCI
78761 77750 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 210 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78761 77761 NCCI
78761 77762 NCCI
78761 77763 NCCI
78761 77776 NCCI
78761 77777 NCCI
78761 77778 NCCI
78761 77789 NCCI
78761 77790 NCCI
78761 78445 NCCI
78761 78761 BCBST
78761 96360 NCCI
78761 96365 NCCI
78761 96372 NCCI
78761 96374 NCCI
78761 96375 NCCI
78761 96376 NCCI
78761 J1642 NCCI
78800 36000 NCCI
78800 36005 NCCI
78800 36410 NCCI
78800 76000 NCCI
78800 76001 NCCI
78800 76376 NCCI
78800 76377 NCCI
78800 76942 NCCI
78800 76998 NCCI
78800 77001 NCCI
78800 77002 NCCI
78800 77750 NCCI
78800 77761 NCCI
78800 77762 NCCI
78800 77763 NCCI
78800 77776 NCCI
78800 77777 NCCI
78800 77778 NCCI
78800 77789 NCCI
78800 77790 NCCI
78800 78445 NCCI
78800 78800 CPT
78800 78808 NCCI
78800 96360 NCCI
78800 96365 NCCI
78800 96372 NCCI
78800 96374 NCCI
78800 96375 NCCI
78800 96376 NCCI
78800 J1642 NCCI
Comprehensive ComponentCode Code Source
78801 36000 NCCI
78801 36005 NCCI
78801 36410 NCCI
78801 76000 NCCI
78801 76001 NCCI
78801 76376 NCCI
78801 76377 NCCI
78801 76942 NCCI
78801 76998 NCCI
78801 77001 NCCI
78801 77002 NCCI
78801 77750 NCCI
78801 77761 NCCI
78801 77762 NCCI
78801 77763 NCCI
78801 77776 NCCI
78801 77777 NCCI
78801 77778 NCCI
78801 77789 NCCI
78801 77790 NCCI
78801 78445 NCCI
78801 78800 NCCI
78801 78801 CPT
78801 78808 NCCI
78801 96360 NCCI
78801 96365 NCCI
78801 96372 NCCI
78801 96374 NCCI
78801 96375 NCCI
78801 96376 NCCI
78802 36000 NCCI
78802 36005 NCCI
78802 36410 NCCI
78802 76000 NCCI
78802 76001 NCCI
78802 76376 NCCI
78802 76377 NCCI
78802 76942 NCCI
78802 76998 NCCI
78802 77001 NCCI
78802 77002 NCCI
78802 77750 NCCI
78802 77761 NCCI
78802 77762 NCCI
78802 77763 NCCI
78802 77776 NCCI
78802 77777 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 211 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78802 77778 NCCI
78802 77789 NCCI
78802 77790 NCCI
78802 78445 NCCI
78802 78800 NCCI
78802 78801 NCCI
78802 78802 CPT
78802 78808 NCCI
78802 96360 NCCI
78802 96365 NCCI
78802 96372 NCCI
78802 96374 NCCI
78802 96375 NCCI
78802 96376 NCCI
78803 36000 NCCI
78803 36005 NCCI
78803 36410 NCCI
78803 76000 NCCI
78803 76001 NCCI
78803 76376 NCCI
78803 76377 NCCI
78803 76942 NCCI
78803 76998 NCCI
78803 77001 NCCI
78803 77002 NCCI
78803 77750 NCCI
78803 77761 NCCI
78803 77762 NCCI
78803 77763 NCCI
78803 77776 NCCI
78803 77777 NCCI
78803 77778 NCCI
78803 77789 NCCI
78803 77790 NCCI
78803 78445 NCCI
78803 78800 NCCI
78803 78801 NCCI
78803 78803 CPT
78803 78808 NCCI
78803 96360 NCCI
78803 96365 NCCI
78803 96372 NCCI
78803 96374 NCCI
78803 96375 NCCI
78803 96376 NCCI
78804 36000 NCCI
78804 36005 NCCI
Comprehensive ComponentCode Code Source
78804 36410 NCCI
78804 76000 NCCI
78804 76001 NCCI
78804 76376 NCCI
78804 76377 NCCI
78804 76942 NCCI
78804 76998 NCCI
78804 77001 NCCI
78804 77002 NCCI
78804 78185 NCCI
78804 78195 NCCI
78804 78201 NCCI
78804 78215 NCCI
78804 78445 NCCI
78804 78800 NCCI
78804 78801 NCCI
78804 78802 NCCI
78804 78808 NCCI
78804 96360 NCCI
78804 96365 NCCI
78804 96372 NCCI
78804 96374 NCCI
78804 96375 NCCI
78804 96376 NCCI
78804 J1642 NCCI
78805 36000 NCCI
78805 36005 NCCI
78805 36011 NCCI
78805 36406 NCCI
78805 36410 NCCI
78805 76000 NCCI
78805 76001 NCCI
78805 76376 NCCI
78805 76377 NCCI
78805 76942 NCCI
78805 76998 NCCI
78805 77001 NCCI
78805 77002 NCCI
78805 77750 NCCI
78805 77761 NCCI
78805 77762 NCCI
78805 77763 NCCI
78805 77776 NCCI
78805 77777 NCCI
78805 77778 NCCI
78805 77789 NCCI
78805 77790 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 212 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78805 78445 NCCI
78805 78805 CPT
78805 78808 NCCI
78805 96360 NCCI
78805 96365 NCCI
78805 96372 NCCI
78805 96374 NCCI
78805 96375 NCCI
78805 96376 NCCI
78805 J1642 NCCI
78806 36000 NCCI
78806 36005 NCCI
78806 36011 NCCI
78806 36406 NCCI
78806 36410 NCCI
78806 76000 NCCI
78806 76001 NCCI
78806 76376 NCCI
78806 76377 NCCI
78806 76942 NCCI
78806 76998 NCCI
78806 77001 NCCI
78806 77002 NCCI
78806 77750 NCCI
78806 77761 NCCI
78806 77762 NCCI
78806 77763 NCCI
78806 77776 NCCI
78806 77777 NCCI
78806 77778 NCCI
78806 77789 NCCI
78806 77790 NCCI
78806 78445 NCCI
78806 78805 NCCI
78806 78806 CPT
78806 78808 NCCI
78806 96360 NCCI
78806 96365 NCCI
78806 96372 NCCI
78806 96374 NCCI
78806 96375 NCCI
78806 96376 NCCI
78807 36000 NCCI
78807 36005 NCCI
78807 36011 NCCI
78807 36406 NCCI
78807 36410 NCCI
Comprehensive ComponentCode Code Source
78807 76000 NCCI
78807 76001 NCCI
78807 76376 NCCI
78807 76377 NCCI
78807 76942 NCCI
78807 76998 NCCI
78807 77001 NCCI
78807 77002 NCCI
78807 77750 NCCI
78807 77761 NCCI
78807 77762 NCCI
78807 77763 NCCI
78807 77776 NCCI
78807 77777 NCCI
78807 77778 NCCI
78807 77789 NCCI
78807 77790 NCCI
78807 78445 NCCI
78807 78805 NCCI
78807 78807 CPT
78807 78808 NCCI
78807 96360 NCCI
78807 96365 NCCI
78807 96372 NCCI
78807 96374 NCCI
78807 96375 NCCI
78807 96376 NCCI
78808 36000 NCCI
78808 36005 NCCI
78808 36410 NCCI
78808 76000 NCCI
78808 76001 NCCI
78808 76942 NCCI
78808 76998 NCCI
78808 77001 NCCI
78808 77002 NCCI
78808 78445 NCCI
78808 96360 NCCI
78808 96365 NCCI
78808 96372 NCCI
78808 96374 NCCI
78808 96375 NCCI
78808 96376 NCCI
78811 36000 NCCI
78811 36005 NCCI
78811 36410 NCCI
78811 70450 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 213 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78811 70480 NCCI
78811 70486 NCCI
78811 70490 NCCI
78811 71250 NCCI
78811 72125 NCCI
78811 72128 NCCI
78811 72131 NCCI
78811 72192 NCCI
78811 73200 NCCI
78811 73700 NCCI
78811 74150 NCCI
78811 74176 NCCI
78811 76376 NCCI
78811 76377 NCCI
78811 78445 NCCI
78811 96360 NCCI
78811 96365 NCCI
78811 96372 NCCI
78811 96374 NCCI
78811 96375 NCCI
78811 96376 NCCI
78811 A4641 NCCI
78811 A9526 NCCI
78811 A9555 NCCI
78811 J1642 NCCI
78812 36000 NCCI
78812 36005 NCCI
78812 36410 NCCI
78812 70450 NCCI
78812 70480 NCCI
78812 70486 NCCI
78812 70490 NCCI
78812 71250 NCCI
78812 72125 NCCI
78812 72128 NCCI
78812 72131 NCCI
78812 72192 NCCI
78812 73200 NCCI
78812 73700 NCCI
78812 74150 NCCI
78812 74176 NCCI
78812 76376 NCCI
78812 76377 NCCI
78812 78445 NCCI
78812 78811 NCCI
78812 96360 NCCI
78812 96365 NCCI
Comprehensive ComponentCode Code Source
78812 96372 NCCI
78812 96374 NCCI
78812 96375 NCCI
78812 96376 NCCI
78812 A4641 NCCI
78812 A9526 NCCI
78812 A9555 NCCI
78812 J1642 NCCI
78813 36000 NCCI
78813 36005 NCCI
78813 36410 NCCI
78813 70450 NCCI
78813 70480 NCCI
78813 70486 NCCI
78813 70490 NCCI
78813 71250 NCCI
78813 72125 NCCI
78813 72128 NCCI
78813 72131 NCCI
78813 72192 NCCI
78813 73200 NCCI
78813 73700 NCCI
78813 74150 NCCI
78813 74176 NCCI
78813 76376 NCCI
78813 76377 NCCI
78813 78445 NCCI
78813 78811 NCCI
78813 78812 NCCI
78813 96360 NCCI
78813 96365 NCCI
78813 96372 NCCI
78813 96374 NCCI
78813 96375 NCCI
78813 96376 NCCI
78813 A4641 NCCI
78813 A9526 NCCI
78813 A9555 NCCI
78813 J1642 NCCI
78814 36000 NCCI
78814 36005 NCCI
78814 36410 NCCI
78814 70450 NCCI
78814 70480 NCCI
78814 70486 NCCI
78814 70490 NCCI
78814 71250 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 214 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
78814 72125 NCCI
78814 72128 NCCI
78814 72131 NCCI
78814 72192 NCCI
78814 73200 NCCI
78814 73700 NCCI
78814 74150 NCCI
78814 74176 NCCI
78814 76376 NCCI
78814 76377 NCCI
78814 78445 NCCI
78814 78811 NCCI
78814 78812 NCCI
78814 78813 NCCI
78814 96360 NCCI
78814 96365 NCCI
78814 96372 NCCI
78814 96374 NCCI
78814 96375 NCCI
78814 96376 NCCI
78814 A4641 NCCI
78814 A9526 NCCI
78814 A9555 NCCI
78814 J1642 NCCI
78815 36000 NCCI
78815 36005 NCCI
78815 36410 NCCI
78815 70450 NCCI
78815 70480 NCCI
78815 70486 NCCI
78815 70490 NCCI
78815 71250 NCCI
78815 72125 NCCI
78815 72128 NCCI
78815 72131 NCCI
78815 72192 NCCI
78815 73200 NCCI
78815 73700 NCCI
78815 74150 NCCI
78815 74176 NCCI
78815 76376 NCCI
78815 76377 NCCI
78815 78445 NCCI
78815 78811 NCCI
78815 78812 NCCI
78815 78813 NCCI
78815 78814 NCCI
Comprehensive ComponentCode Code Source
78815 96360 NCCI
78815 96365 NCCI
78815 96372 NCCI
78815 96374 NCCI
78815 96375 NCCI
78815 96376 NCCI
78815 A4641 NCCI
78815 A9526 NCCI
78815 A9555 NCCI
78815 J1642 NCCI
78816 36000 NCCI
78816 36005 NCCI
78816 36410 NCCI
78816 70450 NCCI
78816 70480 NCCI
78816 70486 NCCI
78816 70490 NCCI
78816 71250 NCCI
78816 72125 NCCI
78816 72128 NCCI
78816 72131 NCCI
78816 72192 NCCI
78816 73200 NCCI
78816 73700 NCCI
78816 74150 NCCI
78816 74176 NCCI
78816 76376 NCCI
78816 76377 NCCI
78816 78445 NCCI
78816 78811 NCCI
78816 78812 NCCI
78816 78813 NCCI
78816 78814 NCCI
78816 78815 NCCI
78816 96360 NCCI
78816 96365 NCCI
78816 96372 NCCI
78816 96374 NCCI
78816 96375 NCCI
78816 96376 NCCI
78816 A4641 NCCI
78816 A9526 NCCI
78816 A9555 NCCI
78816 J1642 NCCI
79005 78012 NCCI
79005 78013 NCCI
79005 78014 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 215 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
79005 78015 NCCI
79005 78016 NCCI
79005 78018 NCCI
79005 78070 NCCI
79005 78071 NCCI
79005 78072 NCCI
79005 78075 NCCI
79005 78232 NCCI
79005 78258 NCCI
79005 78262 NCCI
79005 78264 NCCI
79005 78267 NCCI
79005 78268 NCCI
79005 78270 NCCI
79005 78271 NCCI
79005 78272 NCCI
79005 78445 NCCI
79005 78600 NCCI
79005 78601 NCCI
79005 78605 NCCI
79005 78606 NCCI
79101 36000 NCCI
79101 36400 NCCI
79101 36410 NCCI
79101 78013 NCCI
79101 78014 NCCI
79101 78070 NCCI
79101 78071 NCCI
79101 78072 NCCI
79101 78075 NCCI
79101 78102 NCCI
79101 78103 NCCI
79101 78104 NCCI
79101 78110 NCCI
79101 78111 NCCI
79101 78120 NCCI
79101 78121 NCCI
79101 78122 NCCI
79101 78130 NCCI
79101 78135 NCCI
79101 78140 NCCI
79101 78185 NCCI
79101 78190 NCCI
79101 78191 NCCI
79101 78195 NCCI
79101 78201 NCCI
79101 78202 NCCI
Comprehensive ComponentCode Code Source
79101 78205 NCCI
79101 78206 NCCI
79101 78215 NCCI
79101 78216 NCCI
79101 78226 NCCI
79101 78227 NCCI
79101 78230 NCCI
79101 78231 NCCI
79101 78261 NCCI
79101 78278 NCCI
79101 78282 NCCI
79101 78290 NCCI
79101 78300 NCCI
79101 78305 NCCI
79101 78306 NCCI
79101 78315 NCCI
79101 78320 NCCI
79101 78428 NCCI
79101 78445 NCCI
79101 78451 NCCI
79101 78452 NCCI
79101 78453 NCCI
79101 78454 NCCI
79101 78456 NCCI
79101 78457 NCCI
79101 78458 NCCI
79101 78459 NCCI
79101 78466 NCCI
79101 78468 NCCI
79101 78469 NCCI
79101 78472 NCCI
79101 78473 NCCI
79101 78481 NCCI
79101 78483 NCCI
79101 78491 NCCI
79101 78492 NCCI
79101 78494 NCCI
79101 78580 NCCI
79101 78582 NCCI
79101 78597 NCCI
79101 78598 NCCI
79101 78600 NCCI
79101 78601 NCCI
79101 78605 NCCI
79101 78606 NCCI
79101 78607 NCCI
79101 78608 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 216 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
79101 78610 NCCI
79101 78700 NCCI
79101 78701 NCCI
79101 78707 NCCI
79101 78708 NCCI
79101 78709 NCCI
79101 78710 NCCI
79101 78725 NCCI
79101 78740 NCCI
79101 78761 NCCI
79101 78800 NCCI
79101 78801 NCCI
79101 78802 NCCI
79101 78803 NCCI
79101 78804 NCCI
79101 78805 NCCI
79101 78806 NCCI
79101 78807 NCCI
79101 78808 NCCI
79101 78811 NCCI
79101 78812 NCCI
79101 78813 NCCI
79101 78814 NCCI
79101 78815 NCCI
79101 78816 NCCI
79101 96360 NCCI
79101 96365 NCCI
79101 96372 NCCI
79101 96374 NCCI
79101 96375 NCCI
79101 96376 NCCI
79101 96409 NCCI
79101 96413 NCCI
79101 96415 NCCI
79101 J1642 NCCI
79200 36000 NCCI
79200 36410 NCCI
79200 77750 NCCI
79200 77776 NCCI
79200 77777 NCCI
79200 77778 NCCI
79200 77789 NCCI
79200 77790 NCCI
79200 78291 NCCI
79200 78445 NCCI
79200 78740 NCCI
79200 79200 BCBST
Comprehensive ComponentCode Code Source
79200 96360 NCCI
79200 96365 NCCI
79200 96372 NCCI
79200 96374 NCCI
79200 96375 NCCI
79200 96376 NCCI
79200 J1642 NCCI
79300 36000 NCCI
79300 36410 NCCI
79300 77750 NCCI
79300 77761 NCCI
79300 77762 NCCI
79300 77763 NCCI
79300 77789 NCCI
79300 77790 NCCI
79300 78445 NCCI
79300 79200 NCCI
79300 79300 BCBST
79300 96360 NCCI
79300 96365 NCCI
79300 96372 NCCI
79300 96374 NCCI
79300 96375 NCCI
79300 96376 NCCI
79403 36000 NCCI
79403 36410 NCCI
79403 76000 NCCI
79403 76001 NCCI
79403 76942 NCCI
79403 76998 NCCI
79403 77001 NCCI
79403 77002 NCCI
79403 78185 NCCI
79403 78195 NCCI
79403 78201 NCCI
79403 78215 NCCI
79403 78445 NCCI
79403 78800 NCCI
79403 78801 NCCI
79403 78802 NCCI
79403 78803 NCCI
79403 78804 NCCI
79403 79101 NCCI
79403 96360 NCCI
79403 96365 NCCI
79403 96372 NCCI
79403 96374 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 217 of 218
Effective Date of Service: 1/1/2014
BlueCross BlueShield of TennesseeCommercial Code Bundling Rules
Comprehensive ComponentCode Code Source
79403 96375 NCCI
79403 96376 NCCI
79403 96409 NCCI
79403 96413 NCCI
79403 96416 NCCI
79403 C8957 NCCI
79403 J1642 NCCI
79440 36000 NCCI
79440 36410 NCCI
79440 77776 NCCI
79440 77777 NCCI
79440 77778 NCCI
79440 77789 NCCI
79440 77790 NCCI
79440 78445 NCCI
79440 79440 BCBST
79440 96360 NCCI
79440 96365 NCCI
79440 96372 NCCI
79440 96374 NCCI
79440 96375 NCCI
79440 96376 NCCI
79445 36000 NCCI
79445 36410 NCCI
79445 78445 NCCI
79445 78803 NCCI
79445 78804 NCCI
79445 96372 NCCI
79445 96373 NCCI
79445 96420 NCCI
79445 96422 NCCI
79445 96423 NCCI
CPT® is a registered trademark of the American Medical AssociationCurrent Dental Terminology © 2004 American Dental Association
Code bundling rules subject to additions, deletions, and/or revisions on a quarterly basis.
Print Date: 11/7/2013 BlueCross BlueShield of Tennessee-Coding Bundling Rules Page 218 of 218