Wiki Multiple Add-on codes and reimbursement rates

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kathleenpotts

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How do I determine what an add-on code will actually pay out at? I am a newer biller and from my understanding add-on codes tend to be paid at lower rates than the primary code- sometimes 50% less than even the listed Medicare fee schedule rate- and if you have multiple units of an add-on code, the additional units are paid at an even lower rate. I would just like some help and direction to any correct resources to figure this out, specifically for these add-on codes: 99458, 99425, 99426, 99439, 99437. (Also, if I have misinformation, please let me know!)
 
Reimbursement rates are determined by your contract with the insurance carrier. For any carrier other than Medicare or Medicaid, your contract is the best place to determine this. 5 different physicians on the same block could have 5 different fee schedules with the same carrier.
I am not familiar with billing the care management codes you have listed, but the theory of add on codes is that payment is not reduced for multiple procedures. However, each carrier may set their own policies that could add a reduction.
PS - 99426 is not an add on code per Codify.
 
Agree the contract is the place to go. And also agree it can vary between payers/providers.
Add on codes are usually paid at lower rates essentially because they are add-on codes. Meaning, they aren't stand-alone (with some exceptions) and require a parent to be reported and the parent pays the higher rate (usually). This is also why Modifier 51 is not appended to add-on codes, multiple procedure rules don't apply.
To learn more: https://www.cms.gov/medicare-medica...ci/ncci-medicare/medicare-ncci-add-code-edits

For CMS you can search the fee schedule: https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=3&H1=99458&M=5
 
Hi there, add-on codes will usually have a lower payment rate because the add-on service inherently involves less work/practice expense than the primary service. I wonder if you're thinking of multiple procedure payment reduction?
 
kathleenpotts said:
How do I determine what an add-on code will actually pay out at? I am a newer biller and from my understanding add-on codes tend to be paid at lower rates than the primary code- sometimes 50% less than even the listed Medicare fee schedule rate- and if you have multiple units of an add-on code, the additional units are paid at an even lower rate. I would just like some help and direction to any correct resources to figure this out, specifically for these add-on codes: 99458, 99425, 99426, 99439, 99437. (Also, if I have misinformation, please let me know!)
Click to expand...
Add-on codes, under Medicare RVU pricing methodology, are never subject to reductions because the pricing for the code is already based on the fact that this is a procedure being performed secondary to another principal procedure. Applying a reduction to an add-on code would reduce the value further and would be an underpayment. As has been mentioned above, other payers may have different methodologies based on contractual agreements with providers, but if the payer's payment rates are based on Medicare valuations, then it would be an error to apply a multiple procedure reduction to an add-on code.
 
jkyles said:
Hi there, add-on codes will usually have a lower payment rate because the add-on service inherently involves less work/practice expense than the primary service. I wonder if you're thinking of multiple procedure payment reduction?
Click to expand...
how do you see that working with "multiple procedure payment reduction"?
 
 
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