Pulmonology Coding Alert

Never leave "add-ons" hanging without a primary procedure.

Like it or not, "add-on" (ZZZ) codes are a thing you'll have to deal with in pulmonology. These codes are additions to minor and major surgical procedures, as well as to E/M services. Currently there are 7 "add-on" (ZZZ) codes for bronchoscopy, says Alan L. Plummer, MD, professor of medicine in the Division of Pulmonary, Allergy and Critical Care at the Emory University School of Medicine in Atlanta. There are special guidelines that can help you apply ZZZ codes as you need them, and consequently secure your claim.

1. Add-on Codes Come With a '+' Prefix

There's an easy way to tell if a CPT code is designated as an add-on code. Just look for a plus sign (+) symbol to the left of the code in your CPT manual. Another hint is that in their code descriptors all add-on codes contain a variation of the phrase "List separately in addition to code for primary procedure." "You will also find a listing of the CPT code range in which that add-on code may be used in addition with," says Nicole Martin, CPC, owner of Innovative Coding Analysis in Coplay, Penn. That listing follows the add-on code descriptor in the CPT manual.

For instance, a typical add-on code for pulmonology appears as follows:

+31633 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), each additional lobe [List separately in addition to code for primary procedure]).

You should use this code when a pulmonologist obtains a transbronchial needle aspiration (TBNA) of a lymph node from each lobe separate from the lobe from which an initial TBNA was obtained, Plummer explains.

Tip: CPT designates some E/M services as add-on codes as well. For instance, you may report prolonged services -- such as +99354 (Prolonged physician service in the office or other outpatient setting ...) -- in addition to other primary E/M services such as an outpatient visit. Turn to Appendix D of your CPT manual for a complete list of add-on codes.

2. A Primary Procedure Always Accompanies "Add-Ons"

An essential rule of thumb is to never report an add-on code without also listing a "primary" procedure code on the same invoice.

Why: The add-on code describes additional intra-service work associated with specific primary procedures the physician performs during the same operative session or patient encounter. "You don't report add-on codes alone as they are an integral part of the primary procedure. In which case, CPT and the AMA direct they should be reimbursed in addition to the primary procedure," Martin explains.

"In most cases, add-on codes represent the 'above and beyond' that a provider might do along with the usual services," says Denae M. Merrill, CPC, CEMC, HCC coding specialist for The Coding Source and owner of Merrill Medical Management.

Example: Your pulmonologist would never use endobronchial ultrasound (EBUS) (+31620, Endobronchial ultrasound [EBUS] during bronchoscopic diagnostic or therapeutic intervention(s) [List separately in addition to code for primary procedure]) in the absence of a primary bronchoscopic procedure. Because you would only bill +31620 in addition to another bronchoscopy procedure, CPT lists this code as an add-on.

In many cases, the primary code(s) for a given add-on code immediately precedes the add-on code in the CPT listings. However, several possible add-on codes for bronchoscopy are distributed throughout the family of bronchoscopy codes. For example, 31636 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of bronchial stent[s], [includes tracheal/bronchial dilation as required], initial bronchus) precedes +31637 (Each additional major bronchus stented...).

Scenario: A patient with a chest CT scan showing right paratracheal and right hilar lymphadenopathy undergoes transbronchial needle aspirations with the assistance of endobronchial ultrasound. The right paratracheal and right hilar lymph nodes are biopsied. You would code 31629 (Bronchoscopy ,...; with transbronchial needle aspiration biopsy(s), trachea main stem and/or lobar bronchus[i]) for the right paratracheal node biopsies, +31633 (Bronchoscopy,...; with transbronchial needle aspiration biopsy(s), each additional lobe...) for the right hilar node biopsies and +31620 (Endobronchial ultrasound [EBUS] during bronchoscopic diagnostic or therapeutic interventions...)

for the EBUS used during the bronchoscopy. The two lymph node groups are in different "lobes" allowing the use of +31633. In this example there are two add-on codes, +31633 and +31620, used. Caveat: As noted above, CPT doesn't always list add-on codes directly after all of the primary procedure codes. In case the add-on code and primary code(s) are not listed together, CPT will provide instructions on which code(s) should accompany the add-on code.

3. Modifier 51 and Add-on Codes Don't Go Together

You should never append modifier 51 (Multiple procedures) to a designated add-on code, Merrill says. Modifier 51 designates a procedure or service that can be performed independently but, also is performed at the same time as another procedure.

What CPT says: "All add-on codes found in the CPT book are exempt from the multiple procedure concept."

Reason: "Add-on codes have been given a separately reimbursable value that has already had the applicable discount for multiple procedures at the time the relative value unit(RVU) was assigned," Martin says.

Check your payments: Always check your explanation of benefits (EOB) 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. For example, if you report +31633 in a private setting for subsequent lymph node biopsies during a transbronchial needle aspiration, you should receive the full nonfacility fee of $85.15 (geographically unadjusted Medicare rate) for that code (2.36 relative value units [RVUs], based on the 2010 Medicare Physician Fee Schedule, and the conversion factor [CF] of $36.0791), $260.13 for +31620 (7.21 RVUs) and $587.37 (16.28 RVUs) for the base code, 31629.

"Add-on codes should never be reduced for multiple procedure discounts," Martin warns. "They should always be paid at 100 percent of the contract amount unless you have entered into an insurance contract agreeing to otherwise, such as hospital/facility insurance contracts."

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 as additional procedures exempt from modifier 51 rules.