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Ophthalmology and Optometry Coding Alert

4 Pointers Make 'Add-On' Codes Easy

Published on Wed May 12, 2004

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

When you report "add-on" codes for ophthalmic endoscopy or prolonged physician services, 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: +66990 (Use of ophthalmic endoscope [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 +67335 (Placement of adjustable suture[s] during strabismus surgery, including postoperative adjustment[s] of suture[s]) unless he was already performing strabismus surgery -- for example, 67311 (Strabismus surgery, recession or resection procedure; one horizontal muscle).  

Because you would only bill 67335 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 outpatient visits or consultations.
 
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 procedures 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:

  • 67221 -- Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy (includes intravenous infusion)

  • +67225 -- ... photodynamic therapy, second eye, at single session (list separately in addition to code for primary eye treatment).

    In this case, the add-on code (67225) follows the related primary procedure codes (67221). CPT includes an instructional note, "Use 67225 in conjunction with code 67221."

    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 rules do not apply to add-on codes, and no modifier is necessary to report the add-on services.  "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 (see point 4, below).

    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 inaccurate 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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