Otolaryngology Coding Alert

Although the add-on designation in CPT applies to many procedures and services ranging from E/M (prolonged services) to integumentary (lesion removal and skin grafts) to use of equipment (operating microscope and stereotactic guidance) the codes all share the following characteristics:

They are denoted in the CPT book with a + to the left of the code

The CPT code descriptor will include the words list separately in addition to code for primary procedure or each additional code

They should always be used with other, primary procedures

They should never be listed as a primary procedure

They should never be listed with modifier -51 appended

Payment for these services should never be lowered as a multiple-surgery reduction.

Many of these codes involve measuring or counting. Coders must pay close attention to the information in the operative report and make sure the otolaryngologist accurately describes not only the procedure performed but also, for instance, the size of a repaired wound or the number of excised lesions, says Randa Blackwell, coding specialist with the department of otolaryngology at the University of Maryland in Baltimore.

For add-on codes to be used correctly, the operative report has to be specific, Blackwell says, pointing to destruction-of-lesion codes as an example. When one benign or premalignant lesion is destroyed, the correct code is 17000 (destruction by any method, including laser, with or without surgical curettement, all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions, including local anesthesia; first lesion). Any additional lesions destroyed during the same operative session are coded 17003 (... second through 14 lesions, each [list separately in addition to code for first lesion]). In other words, after the initial lesion is destroyed, 17003 may be reported separately for any additional lesions subsequently destroyed. If four lesions were destroyed, the session should be coded as follows:

17000
17003x3

Note: Some carriers instruct physicians to list 17003 three times, with modifier -59 (distinct procedural service) on the second and third code listed. Others may prefer a 3 in the units box of the HCFA 1500 claim form.

Tip: Carefully note the wording of all codes to determine if they are add-on codes. For example, the next code in the lesion destruction series, 17004 ( 15 or more lesions), is not an add-on code. Furthermore, when this code is used, neither 17000 nor 17003 should be reported.

The only way the coder can correctly bill for this service is if the otolaryngologist noted the number of lesions destroyed. Just writing multiple lesions isnt good enough because it doesnt provide the information the coder needs to fill out the claim form correctly, Blackwell argues.

Similarly, an operative report that describes complex wound repairs must clearly dictate the length of the wound, she says. Most large, complex repairs are now reported in part by using add-on codes, which requires precise measurement of the wound to select the correct code and how many times it can be billed, Blackwell notes.

For example, if the otolaryngologist is repairing a 22-cm wound on the face and neck, the first two codes (13131, repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm; and 13132, 2.5 to 7.5 cm) account for the first 7.5 cm. After that, add-on code +13133 (... each additional 5 cm or less [list separately in addition to code for primary procedure]) is used to report each additional 5 cm repaired. Therefore, Blackwell says, if the otolaryngologist accurately and correctly documented what he or she did, the total repair would be coded as follows:

13131
13132
13133x3

The same principles apply to related procedures, such as full- and split-thickness skin grafts, debridements and skin-level biopsies.

Note: Some add-on codes come in pairs, such as 11000 (debridement of extensive eczematous or infected skin; up to 10% of body surface) and +11001 ( each additional 10% of the body surface [list separately in addition to code for primary procedure]) or 11100 (biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion) and +11101 ( each separate/additional lesion [list separately in addition to code for primary procedure]).

Bill the Full Amount

When reporting add-on procedures, be sure to bill, and subsequently obtain, 100 percent of the payable fee for the procedure. Add-on codes are unlike most other multiple services (i.e., other services performed during the same session as a primary procedures) in that the fee for the service is already reduced in the Fee Schedule .

As a result, neither the otolaryngologist nor the carrier should further reduce fees for these services or procedures. Blackwell suggests checking the explanation of benefits carefully to make sure the carrier did not inadvertently reduce the fee for the add-on procedure, in the mistaken belief that a multiple procedure has been performed.

For the same reason, modifier -51 (multiple procedures) should never be attached to add-on codes. Not only are add-on codes modifier -51 exempt, but using the modifier incorrectly may result in an automatic 50 percent reduction in fees for the service even though the service is already reduced.

Remember that add-on codes should never be used to report a primary procedure. In other words, codes such as 61795 (stereotactic computer assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]) and +69990 (use of operating microscope [list separately in addition to code for primary procedure]) should never be billed on their own.

Note: Both 61795 and +69990 differ from most other add-on codes in that CPT does not include a list of the codes they may be charged with, as is usually the case. For example, otolaryngologists are instructed to use 60512 (parathyroid autotransplantation [list separately in addition to code for primary procedure]) in conjunction with 60500, 60502, 60505, 60212, 60225, 60240, 60252, 60254, 60260, 60270 and 60271 only. Similarly, all the add-on codes in the integumentary section discussed earlier include notes that specifically refer to the codes these services may be added to.

Add-on E/M Services

Like all add-on codes, prolonged services codes (99354-99359) cannot be billed alone, notes Michelle Logsdon, CPC, CCS-P, a coding and reimbursement specialist in Toms River, N.J. These time-based codes also cannot be billed unless the other E/M service provided includes a time component, or reference time.

Although many E/M services, such as new and established patient visits, consultations and hospital admissions, do contain a time component and, therefore, can be prolonged, other codes, notably emergency department services (99281-99285), do not, says Logsdon. As a result, prolonged services cannot be billed with 99281-99285.

To bill for one hour of prolonged services in the office (99354) or hospital (99356), at least 30 minutes of that time must be carefully documented. The other prolonged services codes (99355 and 99357) are used only to record additional 30-minute periods spent with the patient. As such, they further add on to the time already recorded in add-on codes 99354 and 99356, respectively. When these codes are used in addition to 99354 or 99356, at least 15 minutes of the additional 30 minutes claimed must be documented.