New Changes to Add-on codes

An add-on code is a HCPCS/CPT code that describes a service that, with one exception, is always performed in conjunction with another primary service. An add-on code with one exception is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on code with one exception is never eligible for payment if it is the only procedure reported by a practitioner.

Example for an exemption

The Internet Only Manual, Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.12(I) requires a provider to report CPT code 99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)) without its primary code CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) if two or more physicians of the same specialty in a group practice provide critical care services to the same patient on the same date of service. For the same date of service only one physician of the same specialty in the group practice may report CPT code 99291 with or without CPT code 99292, and the other physician(s) must report their critical care services with CPT code 99292.

Add-on codes may be identified in three ways:

(1) The code is listed in CR7501 or subsequent ones as a Type I, Type II, or Type III, add-on code.

(2) On the Medicare Physician Fee Schedule Database an add-on code generally has a global surgery period of “ZZZ”.

(3) In the CPT Manual an add-on code is designated by the symbol “+”. The code descriptor of an add-on code generally includes phrases such as “each additional” or “(List separately in addition to primary procedure).”

Types of Add-on Codes

CMS has divided the add-on codes into three Groups to distinguish the payment policy for each group.

(1) Type I – A Type I add-on code has a limited number of identifiable primary procedure codes. A Type I add-on code, with one exception, is eligible for payment if one of the listed primary procedure codes is also eligible for payment to the same practitioner for the same patient on the same date of service. Claims processing contractors must adopt edits to assure that Type I add-on codes are never paid unless a listed primary procedure code is also paid. Pursuant to Internet Only Manual, Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.12(I) described in the “Background” section of CR 7501, CPT code 99292 may be paid to a physician who does not report CPT code 99291 if another physician of the same specialty in his group practice is paid for CPT code 99291 on the same date of service.

(2) Type II – A Type II add-on code does not have a specific list of primary procedure codes. Claims processing contractors are encouraged to develop their own lists of primary procedure codes for this type of add-on codes. Like the Type I add-on codes, a Type II add-on code is eligible for payment if an acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment to the same practitioner for the same patient on the same date of service.

(3)Type III – A Type III add-on code has some, but not all, specific primary procedure codes identified in the CPT Manual. The CR 7501 lists the Type III add-on codes with the primary procedure codes that are specifically identifiable. However, claims processing contractors are advised that these lists are not exclusive and there are other acceptable primary procedure codes for add-on codes in this Type. Claims processing contractors are encouraged to develop their own lists of additional primary procedure codes for this group of add-on codes. Like the Type I add-on codes, a Type III add-on code is eligible for payment if an acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment to the same practitioner for the same patient on the same date of service.

The complete list of Add-on codes categorized by types and its Primary Codes based on 2013 CPT Manual is available @ http://cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2607CP.pdf