Neurosurgery Coding Alert

Question: I have a discrepancy with a carrier regarding an ACDF. The reimbursement for the primary code (22554) was paid at 100 percent, and the secondary code (63075) was paid at 50 percent, appropriately. The add-on codes 22585 x 2 units were paid at 100 percent of the fee schedule, but add-ons 63076 x 2 were paid at only 50 percent.

New York Subscriber

Answer: No, the payer's reasoning is not correct.

Under no circumstances should a payer devalue reimbursement for a properly reported add-on code. As you note, 63076 is an add-on code and, as such, its payment value already reflects an automatic, "multiple-procedure" reduction. This is true even if the primary procedure code to which that add-on code is linked is itself subject to a multiple-procedure reduction.

In other words: 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.

AMA guidelines as outlined in the CPT manual's "Introduction" state, "All add-on codes found in the CPT codebook are exempt from the multiple-procedure concept."

Note that CMS/Medicare guidelines, as stipulated in the Medicare physician fee schedule database, support the AMA/CPT guidelines for add-on codes in general and for 63076 in particular.

Specifically, if you locate 63076 in the physician fee schedule and look to the "MULT PROC" column, you will find a "0" indicator, which means that multiple-procedure reductions do not apply. The relative values assigned to these codes already take into account their additional nature and, as such, payers should not, under any circumstances, reduce payment further. Often, procedures with a "0" indicator are represented by add-on codes.

The precise CMS language regarding a "0" indicator in the MULT PROC column of the fee schedule stipulates, "No payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure, base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount for the procedure."

You should definitely appeal the payer's decision. Present the payer with the evidence (such as a photocopy of the page in CPT that explains proper use of add-on codes with the relevant phrases highlighted), along with any other references to the appropriate use of add-on codes.