Knowing how to use add-on codes can net you up to $258 in additional reimbursement.
CPT is full of “add-on” codes, additions to minor and major surgical procedures as well as to E/M services. Fortunately for urology there are not many “add-on codes,” but that makes it essential for you to know the special rules that apply to these codes when you do have to use them. If you learn just a few main guidelines, you can gain the best possible reimbursement for your urologist’s procedures including all add-on codes.
Look for the ‘+’ Symbol
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.
Example: For urology a typical add-on code listing appears as follows:
- +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).
Pointer: 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.
Tip: Remember you can find a complete list of add-on codes in Appendix D of your CPT manual.
Always List “Add-Ons” With a Primary Procedure
As noted above, you should never report an add-on code without also listing a “primary” procedure code.
Here’s 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. “Add-on codes do not get reported alone as they are an integral part of the primary procedure in which CPT and the AMA feels 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 urologist would never use an operating microscope (+69990, Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) in the absence of a surgical procedure that required microscopic visualization of a particular anatomic location. Because you would only bill +69990 in addition to another procedure, CPT lists this code as an add-on.
In most cases, the primary code(s) for a given add-on code immediately precede the add-on code in the CPT listings. For example, consider the following CPT code sequence:
- 51728 — Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique
- 51729 — … with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique
- +51797 — Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure).
In this case, the add-on code (+51797) follows the primary procedure codes (51728 and 51729) to which it is related, even though the code is not in numerical order in the CPT manual. Plus, CPT instructs, “Use 51797 in conjunction with codes 51728, 51729.”
Caveat: CPT doesn’t always list add-on codes directly after all of the primary procedure codes. In most cases when 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. For example, CPT states that you should report +57267 with 45560, 57240-57265, 57285. CPT only lists +57267 after 57265, however.
Skip Modifier 51 With Add-on Codes
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, in the cited case, is performed at the same time as another procedure.
CPT stresses this point by stating, “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 procedure 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 +57267 for a mesh insertion procedure, you should receive the full $258 fee for that code (7.16 relative value units [RVUs], based on the 2010 Medicare Physician Fee Schedule, and the conversion factor [CF] of 36.0846).
“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.
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