Wiki Add on codes-I understand that

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annav

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I understand that add on code must be billed with the primary code. Specifically 97597 and 97598. Since add on code 97598 is per each additional 20 sq cm, and the total area is 40 sq cm does this code get billed 2x (once on each line) or does it get billed once with 2 units billed? I cannot find any specific guideline for this. Claims for this are being audited because it is being billed multiple times on one line and is exceeding the number of units allowed per day.
 
It should be billed as 97597 (first 20 cm) + 97598 (add'l 20 cm) = 40 sq cm. Make sure the diagnosis coding is correct as in 707.xx and the appropriate diabetes code or venous insufficiency code.
 
97957 is for the first 20 sq cm, so therefore if the wound is 40 sq cm, you would bill:

97597
97598

The total of these is 40 sq cm

If you are billing 97598 twice (whether on one line or two lines), you are indicating that there was more than 40 sq cm but less than 60 sq cm and hence you have overbilled and been overpaid based on the scenario presented.

As far as how to bill multiple 97598 in the event you need to, it depends on the insurance carrier and what they want as different carriers may want one line with two units or two lines with one unit each.

I think your audit based on the scenario above is not for billing on one or two lines but it appears you are overbilling for 40 sq cm. If you truly did overbill, perform your own audit and refund the money based on a misunderstanding and come clean. Make sure the practice is clean everywhere as this may create a different kind of audit.

If the numbers are large, then I recommend an attorney that specializes in this exact thing. Not just your corporate attorney but one that has dealt with this exact type of problem.
 
Is the total area 40 sq cm? This would be billed with 97597 and 97598 x 1. Or is the total area 60 sq cm? 97597 and 97598 x 2. The add on code is for each additional 20 sq cm after the first 20 sq cm. Most insurance companies want the add on code billed on one line with the number of units. But it's always best to check with each carrier for their specific guidelines espcially since they can vary from state to state.
 
These particular codes are being audited by CMS/RAC. The 40 cm is an example number I am using. I am not sure if they require one line for the add on or if it should be multiple lines for each 20cm.
 
As I stated above, you need to check with the carrier about how they want this to appear on the claim form. For Medicare you need to check the NCD and if there is no National Coverage Decision, then check with your MAC for any LCDs. Unfortunately there is not always a concensus among carriers on how they want these listed on the claim so it's always best to get it straight from the horses mouth (so to speak), preferably in writing. If you can't get it in writing make a note of the question you asked, who you spoke to, what they said and the time and date you spoke to them.

The other issue being, if these are being audited is this a pre-billing audit or have they already been billed. If they've already been billed then it doesn't matter how they want it except going forward. You can't change what you billed unless you send in corrected claims.
 
annav said:
I understand that add on code must be billed with the primary code. Specifically 97597 and 97598. Since add on code 97598 is per each additional 20 sq cm, and the total area is 40 sq cm does this code get billed 2x (once on each line) or does it get billed once with 2 units billed? I cannot find any specific guideline for this. Claims for this are being audited because it is being billed multiple times on one line and is exceeding the number of units allowed per day.
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Allowed units per day for surgical procedures is 1. You can bill multiple line items but only 1 unit per. multiple units is allowable for timed procedures or drugs. I know a number of carriers have allowed using units in the past but many are now standardizing their edits to be more in line with Medicare.
The add on code 97598 is for each additional 20 sq centimenters OR ANY PART THEREOF.
So for 48 sq cm you could do
97597 first 20
97598 second 20
97598 59 for the piece of the next 20
 
I ran into this situation with the add ons 11045-11047. I referred to the MUE which didn't have these codes listed. I sent a email to the person on CMS MUE page . They told me that some codes are not posted to the public, and that the carriers make the decision to bill these codes in units.
 
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