Oxford Health Plans > Medical and Administrative Policies > Oxford's Rebundling Rules

Our Rebundling Rules


Notice pursuant to Section 3224-b(4) of the New York State Insurance Law is hereby given that our claims system utilizes a software package assembled by IntelliClaim (owned by McKesson Health Solutions). This software package contains the Correct Coding Initiative Software by The National Technical Information Service (NTIS) and effective October 6, 2006, ClaimsXten™ software by McKesson.

In addition to the rebundling edits in these two packages, there are approximately 4 significant code pair edits that we have added to these packages in order to align the claims system with our reimbursement policies and payment rules. These additional edits are:

99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)
99241 Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. A4550 Surgical trays
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. A4550 Surgical trays
97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes 97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
We have also made significant changes to the basic software packages described above by removing code pair edits. This has the effect of permitting payment for services that otherwise would have been denied or rebundled because of standard code pairs. Code pairs were deleted in order to align our claims adjudication system with our reimbursement policies and payment rules. They fall into one or more of the following clinical categories:
  • Infusion/Injections with E&M (Evaluation and Management) codes
  • Prolonged Services
  • After Hours Services
  • Immunization administrations
  • Dialysis and E&M services
  • Pulmonary Function Tests and E&M services
  • Allergy Testing and E&M services
  • Chemotherapy Infusions and E&M services
  • Venipuncture
  • Specimen handling when done at the time of in office visits/procedures


Revised: January 13, 2012



The services described in our policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, our policies do not apply to Medicare Advantage enrollees. We reserve the right, in our sole discretion, to modify policies as necessary without prior written notice unless otherwise required by our administrative procedures or applicable state law. The terms "we" and "our" includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to self-funded members and certain insured products. Refer to the member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.