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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 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. 
 
The rules say that modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
The rules say that a status indicator of P means these are bundled/excluded codes. There are no relative value 
units (RVUs) and no payment amounts for these services. No separate payment is made for them under the fee 
schedule. If the item or service is covered as incident to a physician service and is provided on the same day as 
a physician service, payment for it is bundled into the payment for the physician service to which it is incident (an example is an elastic bandage furnished by a physician incident to a physician service). If the item or 
service is covered as other than incident to a physician service, it is excluded from the fee schedule (for 
example, colostomy supplies) and is paid under the other payment provision of the Act. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say that modifiers are used to identify therapy services whether or not financial limitations are in 
effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy 
modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of 
applicable therapy codes except as noted in 20 of this chapter. Consult 20 for the list of codes to which 
modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not 
qualified and recognized by Medicare to perform. The claim must include one of the following modifiers to 
distinguish the discipline of the plan of care under which the service is delivered: 
-GN Services delivered under an outpatient speech-language pathology plan of care;  
-GO Services delivered under an outpatient occupational therapy plan of care; or,  
-GP Services delivered under an outpatient physical therapy plan of care. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 5, Section 20.1. 
 
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.