Part B Insider (Multispecialty) Coding Alert

Published on Fri Apr 30, 2004 PDF

Don't accept payment reductions, or you could lose up to 50% on every claim

When you report "add-on" codes, do you know the special rules that apply? If you can keep just four points in mind, you can gain the best possible reimbursement for your add-on procedures every time.
 
1) Look for a "+" symbol to the left of the code. Also, all add-on codes contain some variation of "list separately in addition to code for primary procedure" in their CPT descriptors.

"The 'plus' designation identifies those codes that the physician performs in addition to other, usually closely related, procedures or services," says Tara L. Conklin, an instructor for CRN-Institute. "That's why they are called 'add-on' codes: You cannot report them alone, but always 'add them on' to another procedure or service."

Some E/M services qualify as add-on codes, as well. For instance, you may report prolonged services (such as +99354, Prolonged physician service ...; first hour; and +99355, ... each additional 30 minutes) only in addition to other, primary E/M services (such as an outpatient visit, consult, etc.).

2) You should never list an add-on code without also listing a "primary" procedure. Rather, the add-on code describes additional intraservice work associated with specific primary procedure codes the physician performs during the same operative session or patient encounter, says Anita L. Carter, an instructor at A+ Medical Management and Education, a school for billing and coding in Absecon, N.J. In most cases, the primary code(s) for a given add-on code immediately precede the add-on code.

When CPT does not list the add-on code and primary codes together, the manual usually provides instructions on which codes should accompany the add-on code.

3) You should never append modifier -51 (Multiple procedures) to a designated add-on code. "Because add-on codes are defined as additional services, the -51 modifier is redundant and, for some payers, can even negatively affect your reimbursement," Conklin says.

4) Always check your explanation of benefits carefully for claims with add-on codes to make sure the payer is reimbursing you the entire fee schedule rate for the billed procedures or services. Often, when a surgeon performs multiple procedures, the payer will reduce payment for the second and subsequent procedures because the presurgery evaluation and preparation and the postsurgical care have been included in the cost of the first procedure. This logic doesn't apply to add-on procedures, because their reimbursement already reflects their additional status, Carter says.