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General Surgery Coding Alert

4 Pointers Make 'Add-On' Codes Easy

Published on Mon Mar 29, 2004

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.

Point 1: Look for the '+'

To identify add-on codes in CPT, you should look for a "+" symbol to the left of the code. Also, all add-on codes contain a variation of the phrase "list separately in addition to code for primary procedure" in their CPT descriptors. A typical add-on code listing appears as follows:

+44955 -- Appendectomy; when done for indicated purpose at time of other major procedure (not as a separate procedure) (list separately in addition to code for primary procedure).

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

Here's an example: A surgeon would never report +48400 (Injection procedure for intraoperative pancreatography [list separately in addition to code for primary procedure]) unless he had to visualize the pancreas for biopsy or excision (for example, 48155, Pancreatectomy, total). Because you would only bill 48400 in addition to another procedure, CPT lists the code as an add-on.

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.).

Note: For a complete list of add-on codes, see Appendix D of CPT.

Point 2: Always List With a Primary Procedure

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, LPN, CPC, 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 in the CPT listings. For example, consider the following CPT code sequence:

  • 13131 -- Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm
  • 13132 -- ... 2.6 cm to 7.5 cm
  • +13133 -- ... each additional 5 cm or less (list separately in addition to code for primary procedure).

    In this case, the add-on code (13133) follows the related primary procedure codes (13131 and 13132). And, CPT includes an instructional note, "Use 13133 in conjunction with code 13132."

    Look out for exceptions: CPT does not list all add-on codes in proximity to their primary procedure codes. In most cases, when CPT does not list the add-on code and primary codes together, the manual provides instructions on which codes should accompany the add-on code. For example, CPT states that you should report +35686 (Creation of distal arteriovenous fistula during lower extremity bypass surgery [non-hemodialysis] [list separately in addition to code for primary procedure]) with 35556, 35566, 35571, 35583-35587, 35623, 35656, 35666 and 35671 -- all of which appear in different portions of CPT.
     
    Point 3: Don't Use Modifier -51

    You should never append modifier -51 (Multiple procedures) to a designated add-on code, Conklin says. Modifier -51 designates a procedure or service usually performed independently but that, in the cited case, the surgeon has performed during the same operative session as another procedure. "Because add-on codes are defined as additional services, the -51 modifier is redundant and, for some payers, can even negatively affect your reimbursement" (see point 4, below), Conklin says.

    CPT stresses this point by stating, "All add-on codes found in the CPT book are exempt from the multiple-procedure concept."

    Point 4: Don't Accept Devalued Payments

    Always 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. 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 does not apply to add-on procedures, however.

    "The fee schedule amounts assigned to add-on codes are valued to reflect their status as 'additional procedures.' Any further reduction in reimbursement below the fee schedule amount represents an unreasonable devaluation of payment," Carter says.

    Fight reductions: If you find a payer reducing the fees for your add-on codes, be sure to appeal the claims. Cite the definition of add-on codes (explained in the "Introduction" portion of CPT) as additional procedures exempt from modifier -51 rules.

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