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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 A/B Medicare Administrative Contractors (MACs) (B) may not pay for the technical 
component (TC) of radiology services furnished to hospital patients. Payment for physicians radiological 
services to the hospital, e.g., administrative or supervisory services, and for provider services needed to 
produce the radiology service, is made by the A/B MAC (A) to the hospital as a provider service. A/B MACs 
(A) include the TC of radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in 
the prospective payment system (PPS) payment to hospitals. Hospital bundling rules exclude payment to 
suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay. The TC of radiology and 
other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment 
System (OPPS) to the hospital. You can find this information in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual Chapter 13, 
Section 20.2.1. 
 
The rules say a Professional Component (PC)/Technical Component (TC) Indicator of 5 = Incident to Codes: This 
indicator identifies codes that describe services covered incident to a physicians service when they are provided by 
auxiliary personnel employed by the physician and working under his or her direct supervision. Payment may not be 
made by carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient 
department. Modifiers 26 and TC cannot be used with these codes. You can find this information in the Centers 
for Medicare and Medicaid Services (CMS), Internet-Only Manual Publication 100-04, Medicare Claims 
Processing Manual Chapter 23, Section 50.6. 
 
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. An add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 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 Medicare Physician's Fee Schedule Database (MPFSDB) Status Code of P is defined as 
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. 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 30.2.2. 
 
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.