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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say CMS developed the National Correct Coding Initiative (NCCI) program to prevent inappropriate 
payment of services that should not be reported together. Each edit table contains edits which are pairs of 
HCPCS/CPT codes that in general should not be reported together. Each edit has a Column One and Column 
Two HCPCS/CPT code. If a provider reports the 2 codes of an edit pair, the Column Two code is denied, and 
the Column One code is eligible for payment. However, if it is clinically appropriate to use an NCCI PTP 
associated modifier, both the Column One and Column Two codes are eligible for payment. Modifiers may be 
appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier 
shall not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances 
do not justify its use. If the Medicare program imposes restrictions on the use of a modifier, the modifier may 
only be used to bypass an NCCI PTP edit if the Medicare restrictions are fulfilled. Modifiers that may be used 
under appropriate clinical circumstances to bypass an NCCI PTP edit include: 
 
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI 
Global surgery modifiers: 24, 25, 57, 58, 78, 79 
Other modifiers: 27, 59, 91, XE, XS, XP, XU 
 
Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of 1 indicates that NCCI PTP-
associated modifiers may be used to bypass an edit under appropriate circumstances. Medicare coding rules 
indicate the CPT code 21470 is found under Column Two of the edit pair; CPT code 21465 is found 
under Column One. Most of these PTP edit have a modifier indicator of 1, which indicates modifiers associated 
with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit and 
Column two code is denied as the mutually exclusive procedures cannot reasonably be performed at the same 
anatomic site or same beneficiary encounter. You can find this information in Medicare's CMS National 
Physician Fee Schedule (NPFS) Relative Value (RVU) File.  
Medicare says that there are specific rules for the time spans before and after surgery that are considered part of 
the surgical procedure. This time span is called a Global Surgical Package. The Medicare Fee Schedule Data 
Base (MFSDB) provides the postoperative periods that apply to each surgical procedure. They can be 0 days, 
10 days or 90 days. If there is an indicator of 000, postoperative visits beyond the day of the procedure are not 
included in the payment amount for the surgery.  You can find this rule at Medicare Claims Processing Manual 
Chapter 12 Section 40.1. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.