Orthopedic Coding Alert

If you missed that spinal bone graft codes 20930-20938 became add-on codes in 2008, you could be making costly mistakes on your claims. Here's a look at the rules you should apply to be sure you get maximum payment for these spine claims -- and any add-on claims.

You should never report an add-on code alone. By definition, an add-on code describes an "additional" service that occurs only at the same time as another, more extensive procedure, says Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the department of surgery at the University of Pittsburgh Medical Center. Generally, CPT will include an editorial note, following the add-on code's descriptor, to instruct you as to which primary procedure codes should precede that add-on code.

Example: For all spinal bone graft procedures 20930-20938, the appropriate, approved primary procedures are 22319 (fracture treatment) and 22532-22533, 22548-22558, 22590-22612, 22630 and 22800-22812 (arthro-desis/spinal fusion).

You can find these instructions immediately following each of the code descriptors for 20930-20938.

You may occasionally report more than one type of add-on code during the same operative session.

For instance, in addition to arthrodesis, spinal bone grafts also frequently occur during the same session as spinal instrumentation procedures (22840-22855). The spinal instrumentation procedures are represented with add-on codes, and you may report them in addition to any spinal bone grafts and arthrodesis.

CPT supports this coding with instructions preceding both the arthrodesis and spinal instrumentation codes advising, "To report bone graft procedures, see 20930-20938. (Report in addition to code[s] for definitive procedure[s].)" And although the Correct Coding Initiative (CCI) bundles various bone grafts into many orthopedic procedures, such bundles do not apply to spinal bone grafts with arthrodesis (22548-22812) and/or spinal instrumentation (22840-22855) procedures.

You should never append modifier 51 (Multiple procedures) to a designated add-on code.

Modifier 51 designates a procedure or service that a provider usually performs independently but, in the cited case, performs it at the same time as another procedure. Because CPT already defines add-on codes as additional services or procedures, modifier 51 is redundant and, for some payers, can even harm your reimbursement, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, manager of compliance education at the University of Washington Physicians.

CPT stresses this point by stating, "All add-on codes found in the CPT book are exempt from the multiple procedure concept." That is, the payment value assigned to these codes reflects their status as "additional procedures," and therefore any further reduction in reimbursement is unwarranted and unjustified.

The AMA's CPT 2008 Changes: An Insider's View goes even further, stating, "As modifier 51 exempt codes are typically adjunctive or reported with other procedures, the amount of pre- and post-service time associated with these codes is minimal and use of modifier 51 to signify further reduction would be inappropriate." It further states, "Both add-on and modifier 51 exempt codes are similar in that neither should be subject to multiple procedure reductions."

Returning to the example of spinal bone grafts, going as far back as February 1996, CPT Assistant stated, "Codes 20930-20938, although appearing under the heading of General Musculoskeletal Procedures, apply only to bone grafts used for spine surgery ... These are specifically identified as add-on procedures. The 51 modifier is not used when these codes are reported with the definitive spine surgery code."

Always check your explanation of benefits carefully for claims with add-on codes to be sure the payer reimburses you the entire fee schedule rate for the billed procedures or services.

Often, when a physician performs multiple procedures, the payer will reduce payment for the second and subsequent procedures because the first procedure's cost already covers the pre-surgery evaluation, preparation and postsurgical care, Bucknam says. As explained above, however, this logic does not apply to add-on procedures.

Fight reductions: If you find a payer reducing the fees for your add-on codes (not just for spinal bone grafts, but for any add-on procedure), be sure to appeal the claims. Cite AMA guidelines from the CPT Manual's "Introduction," which clearly state, "All add-on codes found in the CPT book are exempt from the multiple procedure concept."

Although the "add-on" designation in CPT applies to many procedures and services, from E/M to surgical procedures to use of equipment, all add-on codes share the following characteristics:
- the CPT manual marks them with a "+" to the code's left
- the CPT code descriptor includes some version of the phrase "list separately in addition to code for primary procedure"
- you should always use them with a "primary" procedure (parent) code(s)
- you should never list them as a primary procedure
- you should never append modifier 51 to them
- the multiple-surgery reduction should not lower payment for these services.