CPT Codes that are Bundled into other Services and are not Paid

Separately

Under TRICARE's reimbursement policy, TRICARE will follow Medicare’s bundling provisions for professional
services. Beginning October 1, 2013, all services integral to accomplishing a procedure are considered bundled into
that procedure and, therefore, are considered a component part of the comprehensive code. Many of these generic
activities are common to virtually all procedures and, on other occasions, some are integral to only a certain group of
procedures, but are still essential to accomplish these particular procedures. Accordingly, it is inappropriate to
separately bill these services based on standard medical and surgical principles.

The following list of CPT/HCPCS Codes specifies those services that are not paid separately, and will be updated
annually in a separate TAB as part of the Annual CMAC Update.

CPT only © 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Care
CPT/HCPCS
Description Care Effective Date Termination
Code
Date
0537T BLD DRV T LYMPHCYT CAR-T CLL 20190201 99990101
0538T BLD DRV T LYMPHCYT PREP TRNS 20190201 99990101
0539T RECEIPT&PREP CAR-T CLL ADMN 20190201 99990101
15850 REMOVAL OF SUTURES 20190201 99990101
20930 SP BONE ALGRFT MORSEL ADD-ON 20190201 99990101
20936 SP BONE AGRFT LOCAL ADD-ON 20190201 99990101
22841 INSERT SPINE FIXATION DEVICE 20190201 99990101
34839 PLANNING OF PAT-SPEC FENESTR VISC AORTIC DNDOGRFT 20190201 99990101
36000 PLACE NEEDLE IN VEIN 20190201 99990101
38204 BL DONOR SEARCH MANAGEMENT 20190201 99990101
90885 PSY EVALUATION OF RECORDS 20190201 99990101
92531 SPONTANEOUS NYSTAGMUS STUDY 20190201 99990101
92532 POSITIONAL NYSTAGMUS TEST 20190201 99990101
92533 CALORIC VESTIBULAR TEST 20190201 99990101
92534 OPTOKINETIC NYSTAGMUS TEST 20190201 99990101
92618 EX FOR NONSPEECH DEV RX ADD 20190201 99990101
92921 PTCA, EA ADDL BRANCH OF MAJ ARTERY (LIST SEP) 20190201 99990101
92925 PTC ATHERECTOMY, EA ADDL BRANCH (LIST SEP) 20190201 99990101
92929 PERCUT TRANSCATH PLCMT STENT, EA ADDL BRANCH 20190201 99990101
92934 PTC ATHERECTOMY W/STENT, EA ADDL BRANCH 20190201 99990101
92938 PERCUT TRANSLUM REVASC CABG, EA ADDL BRANCH 20190201 99990101
92944 PERCUT TRANSLUM REVASC CHRON OCC, EA ADDL BR. 20190201 99990101
93770 MEASURE VENOUS PRESSURE 20190201 99990101
94150 VITAL CAPACITY TEST 20190201 99990101
97010 HOT OR COLD PACKS THERAPY 20190201 99990101
97602 WOUND(S) CARE NON-SELECTIVE 20190201 99990101
99000 SPECIMEN HANDLING 20190201 99990101
99001 SPECIMEN HANDLING 20190201 99990101
99002 DEVICE HANDLING 20190201 99990101
99024 POSTOP FOLLOW-UP VISIT 20190201 99990101
99050 MEDICAL SERVICES AFTER HRS ADDON 20190201 99990101
99051 MED SERV EVE/WKEND/HOLIDAY ADDON 20190201 99990101
99053 MED SERV 10PM-8AM 24 HR FACIL ADDON 20190201 99990101
99056 MED SERVICE OUT OF OFFICE ADDON 20190201 99990101
99058 OFFICE EMERGENCY CARE ADDON 20190201 99990101
99060 OUT OF OFFICE EMERG MED SVC ADDON 20190201 99990101
99078 GROUP HEALTH EDUCATION 20190201 99990101
99100 ANES FOR PT OF EXTREME AGE ADDON 20190201 99990101
99116 ANES WITH HYPOTHERMIA ADDON 20190201 99990101
99135 ANES WITH CONTROLLED HYPOTENSN ADDON 20190201 99990101
99140 ANES EMERGENCY COND ADDON 20190201 99990101
99288 DIRECT ADVANCED LIFE SUPPORT 20190201 99990101
99339 DOMICIL/R-HOME CARE SUPRVSN 15-29 MIN 20190201 99990101
99340 DOMICIL/R-HOME CARE SUPRVSN 30+ MIN 20190201 99990101
99366 TEAM CONF W/PAT BY HC PRO 20190201 99990101
99367 TEAM CONF W/O PAT BY PHYS 20190201 99990101
99368 TEAM CONF W/O PAT BY HC PRO 20190201 99990101
99374 HOME HEALTH CARE SUPERVISION 20190201 99990101
99485 SUPV. INTERFAC TX CRIT ILL PED PAT, 1ST 30 MIN. 20190201 99990101
99486 SUPV. INTERFAC TX CRIT ILL PED PAT, EA ADDL 30 MIN. 20190201 99990101
A0380 BLS MILEAGE (PER MILE) 20190201 99990101
A0382 BLS ROUTINE DISPOSABLE SUPPLIES 20190201 99990101
A0384 BLS SPEC. SVCS, DISP. SUPPLIES (DEFIB) 20190201 99990101
A0390 ALS MILLEAGE (PER MILE) 20190201 99990101
A0392 ALS SPEC. SVCS, DISP. SUPPLIES (DEFIB) 20190201 99990101
A0394 ALS SPEC. SVCS, DISP. SUPPLIES (IV THERAPY) 20190201 99990101
A0396 ALS SPEC. SVCS, DISP. SUPPLIES (ESOPHAGEAL INTUB.) 20190201 99990101
A0398 ALS ROUTINE DISPOSABLE SUPPLIES 20190201 99990101
A0422 AMBULANCE (ALS/BLS) OXYGEN/SUPPLIES 20190201 99990101
A0424 EXTRA AMBULANCE ATTENDANT 20190201 99990101
G0269 PLACE OCCLUSIVE DEVICE IN VEIN/ART ACCESS SITE 20190201 99990101
Q3031 COLLAGEN SKIN TEST 20190201 99990101
R0076 TRANSPORT PORTABLE EKG 20190201 99990101