February 01, 2014
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
Throughout the CPT® codebook, you will find designated “add on” codes. Add-on codes are identified throughout the CPT® manual by a “+,” and their descriptors will contain a variation of the phrase “report in addition to code for primary procedure.” You also can find a complete list of add-on codes in Appendix D of the CPT® codebook.
Three simple tips can help you to apply add-on codes appropriately.
1. Add-on codes describe procedures or services that are always provided “in addition to” other, related services or procedures. Add-on codes cannot stand alone as separately reportable services.
A persistent problem with add-on codes is identifying which code(s) may be reported as primary with a particular add-on. CPT® sometimes provides explicit instruction as to which codes may be primary with a particular add-on code (e.g., “Use 64148 in conjunction with 36147”) – but not always. But, the CMS Manual System provides a handy reference to allow you to identify quickly if your add-on/primary code pair is allowable. CMS Transmittal 2636 (CR 7501, Jan. 16, 2013) classifies add-on codes as one of three types:
Type I – This type of add-on code has a limited number of identifiable primary procedure codes.
Type II – These add-on codes do not have a specific list of primary procedure codes. CMS encourages claims processing contractors to develop their own lists of primary procedure codes for this type of add-on codes.
Type III – The third type of add-on code has some, but not all, specific primary procedure codes identified in the CPT® manual. CMS advises claims processing contractors that the primary procedure codes in the CPT® manual are not exclusive, and encourages contractors to develop their own lists of additional primary procedure codes.
The transmittal lists each add-on CPT® code, identifying it as either a Type I, Type II or Type III. For those add-ons identified as Type I, the transmittal lists the acceptable primary procedure codes.
Note that the code pairings in the transmittal are based on Medicare – rather than AMA – guidelines. In almost all cases, CMS instructions match those in the CPT® manual, but there are exceptions. For example, CPT® allows separate reporting for use of an operating microscope (+69990) with many dozens of codes from throughout the CPT® manual (including Category III codes); whereas, CMS allows 69990 with relatively few codes from the 6xxxx-series.
For the small number of Type II and Type III codes, you’ll have to rely on your individual payer for guidance – but at least you’ll be able to identify those codes quickly.
2. Add-on codes have no global period assigned. They are instead “included” in the global surgical fee for the primary procedure.
3. Add-on codes are “modifier 51 exempt” and therefore are to be paid at full fee schedule value. Their assigned value accounts for the “additional” nature of the procedure.
Bonus Tip: Periodically check your explanation of benefits carefully for claims with add-on codes to be sure the payer is reimbursing you the entire fee schedule rate for the billed procedures or services. If you find a payer reducing the fees for your add-on codes, appeal the claims.