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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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
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 & Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules state that all diagnostic X-Ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary and tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary. While a physician order is not required to be signed, the physician must clearly document, in the medical record, the intent that the test be performed. Contractors shall 
consider order requirements for diagnostic laboratory tests met if there is: 
 
1. A signed order or signed requisition listing the specific test; or 
2. An unsigned order or unsigned laboratory requisition listing the specific tests to be performed and an 
authenticated medical record that supports the physician/practitioners intent to order the tests; or 
3. An authenticated medical record that supports the physician/practitioners intent to order the specific tests.  
 
You can find these rules in Medicare Program Integrity Manual Chapter 6, Section 6.9.1. 
 
The rules say that certain modifiers can be appended to a code that would typically not be separately paid due 
to National Correct Coding Initiative (NCCI) edits if the service at issue is separate.  The modifiers to indicate 
these separate services are as follows: 
 
1. The 59 modifier is to be used to indicate that a procedure or service is distinct or independent from other 
services performed on the same day. The documentation must support a different session, different procedure 
or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not 
ordinarily encountered or performed on the same day by the same individual. 
 
2. The XE modifier is to be used to indicate that a service is distinct because it occurred during a separate 
encounter on the same date of service. 
 
3. The XS modifier is to be used to indicate that a service is distinct because it was performed on a separate 
organ/structure. 
 
4. The XP modifier is to be used to indicate that a service is distinct because it was performed by a different 
practitioner. 
 
5. The XU modifier is to be used to indicate that a service is distinct because it does not overlap usual 
components of the main service. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Medicare Learning Network (MLN) 
Fact Sheet entitled Proper Use of Modifiers 59, XE, XP, XS, and XU. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.