Claim Payment Policy

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Title:

Add-on Codes

Policy #:

00.10.20e

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Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified. In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits. For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to identify all current add-on codes, as defined by the American Medical Association's Current Procedural Terminology (CPT).

For information on policies related to this topic, refer to the Cross References Table in this policy.

Description

Most procedures or services are reported using stand-alone codes that describe the entire procedure or service being performed. However, in certain circumstances it is necessary to report additional procedure codes beyond the primary procedure or service in order to completely describe what is being performed. Add-on codes represent additional or supplemental procedures or services that are commonly carried out in addition to the primary procedure or service. Add-on codes may describe the work associated with the primary procedure or service for different anatomical sites (eg, additional digit[s], lesion[s], segment[s], tendon[s], joint[s]) or additional segments of time. Add-on codes apply only to procedures or services that are performed by the same physician who performed the primary procedure or service.

Add-on codes are not stand-alone codes; they are reported in addition to the primary procedure code. Multiple surgery reduction logic is not applied to procedure codes classified by Current Procedural Terminology (CPT) as add-on procedure codes. It is not appropriate to report add-on codes with Modifier 51.

Policy

Procedure codes that are identified by Current Procedural Terminology (CPT) as add-on procedure codes are considered for reimbursement when all of the following criteria are met: The associated primary procedure or service is a covered procedure or service. There are no other rules or policies that establish ineligibility for coverage or reimbursement. The add-on procedure code is reported in conjunction with the associated primary procedure code. Add-on codes are not eligible when reported as stand-alone codes. The same physician performs both the primary procedure or service and the additional or supplemental procedure or service that is represented by the add-on code. Multiple surgery reduction logic is not applied to procedure codes classified by CPT as add-on procedure codes. It is not appropriate to report add-on codes with Modifier 51. Refer to Attachment A for a list of procedure codes that are classified by CPT as add-on procedure codes.

Guidelines

This policy is consistent with add-on code guidelines as defined by Current Procedural Terminology (CPT).

This policy is applicable to all products.

All add-on codes listed in Attachment A are exempt from multiple surgery guidelines and should not be appended with Modifier 51.

The postoperative period and global surgery rules that apply to the primary service do not apply to the associated add-on code.

BENEFIT APPLICATION
Subject to the terms and conditions of the applicable benefit contract, procedures or services that are represented by add-on codes are covered under the medical benefits of the Company's products when the medical criteria for the services are met. Specific policies that address certain procedures or services represented by add-on codes may supersede the coverage and/or eligibility of these particular codes.

References

American Medical Association (AMA). CPT® Assistant Archives: 1990-2002.Chicago, IL: AMA; 2003. Beebe M, Dalton JA, Espronceda M, Evans DD, Glenn RL, eds. Current Procedural Terminology: CPT® 2008. Appendix D. Chicago, IL: American Medical Association; 2008. Highmark Medicare Services. Medicare Part B Reference Manual. Chapter 22: global surgery and related issues. [Highmark Medicare Services Web site]. January 2006. Available at: http://www.highmarkmedicareservices.com/partb/refman/pdf/chapter22.pdf. Accessed December 5, 2007.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	Refer to Attachment A
ICD Procedure	N/A
ICD Diagnosis	N/A
HCPCS Level II	N/A
Revenue Codes	N/A

Cross References

Version Effective Date: 01/01/2010