Urology Coding Alert

Skip modifier 51 with add-ons. 

Often, your urologist will perform a procedure along with a second procedure, for which he deserves payment. Some of the procedures have their own “add-on code.” If you’re omitting or adding these improperly, chances are you’re losing deserved pay with every claim. Read on for a refresher on reporting the base code and accurately documenting the indication and the procedure for add-ons to unblock jammed payment.

Tip: 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 helpful 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.”

Don’t Overlook Primary Procedure

Remember that an add-on code cannot be a standalone code. You will need an accompanying primary procedure code. An add-on code hence is indicative of an additional intra-service work that your urologist does in a single session or patient encounter. 

An example is the add-on code +57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [List separately in addition to code for primary procedure]) for mesh insertion. 

Common urogynecology primary procedures which allow billing in addition for the mesh insertion include: 45560 (Repair of rectocele [separate procedure]), 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), 57250 (posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), 57260 (Combined anteroposterior colporrhaphy), 57265 (…with enterocele repair), and 57285 (Paravaginal defect repair [including repair of cystocele, if performed]; vaginal approach).

Exception: You will come across a number of add-on codes which are not listed with the codes of the primary procedure. In these instances, you will look to confirm which code needs to be listed as primary with the add-on code. An example is the “add-on” E/M code 99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour [List separately in addition to code for inpatient Evaluation and Management service]). CPT® mentions that this code be reported only in conjunction with  99218-99220, 99221-99223, 99224-99226, 99231-99233, 99251-99255, 99304-99310, 90822, 90829.

Avoid Modifier 51

You should never append modifier 51 (Multiple procedures) to an add-on code that you are reporting. “Do not add the 51 (Multiple procedures) modifier to an add-on code,” says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior coder & auditor, The Coding Network, Washington.

CPT® clearly specifies “All add-on codes found in the CPT® book are exempt from the multiple-procedure concept.”

Earn Your Deserved Payment

Make sure your payment is in accordance to the fee schedule rate. Note that the fee schedule amounts assigned to add-on codes already reflect their status as “additional procedures.” The logic of reduction of payment for the second and other following procedures when the surgeon does multiple procedures does not apply to the add-on procedures. 

Appeal claims if payment has been reduced or denied for add-on codes. You can cite in support the CPT® definition of add-on codes as “additional procedures exempt from modifier 51 rules.” “The CPT® definition of add-on codes can be found in the Introduction section of the CPT® Manual and a complete list of add-on codes is found in Appendix D,” adds Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey.