Medical Coding Pro

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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Attach your procedure notes and the OIG’s report to pack extra punch.

Even if you follow all of CMS’s rules in reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), your Medicare payer may sometimes still choose to deny your claim.

If you feel you deserve the pay for the EM service you performed, you should appeal the denial. Alice Kater, CPC, PCS, coder with Urology Associates of South Bend in Indiana, offers the following sample appeal letter (below) as an example of how she has challenged her payer to collect rightful reimbursement.

What you should know: To improve her odds of success, Kater submits her physician’s documentation with the appeal letter, as well as a copy of a 2005 letter from Mark B. McClellan, MD, PhD, former HHS administrator, to Inspector General Daniel R. Levinson that was a response to the 2005 OIG report “Use of Modifier 25.”

In addition, Kater includes the first three pages of the OIG report, which outlines the appropriate way to report modifier 25. You can download McClellan’s letter, as well as the OIG report, at http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.

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Make sure your documentation supports the additional substantial complexity of the hernia repair and mesh.

Question: A patient presented for a colectomy for colon cancer. The physician also discovered that the patient had a ventral incarcerated hernia that required a complex repair using mesh. Because of the separate work, we reported 44140 and then reported 49561 with modifier 59. The payer denied the claim. Were we wrong to append modifier 59?

Mississippi Subscriber

Answer: You might think you can append modifier 59 (Distinct procedural service) to the hernia repair code and bill it separately. After all, the hernia repair seems to qualify as a different reason for surgery than the colectomy — for example, if the patient has a recurrent hernia. But modifier 59 tells the payer the hernia repair happened at a separate session, which isn’t true in your case.

If the physician’s documentation proves justification, you might try …

… appending modifier 22 (Unusual procedural services) to the colectomy code because of the extra complexity, time, and effort required by the complex hernia repair with mesh.

The Correct Coding Initiative (CCI) considers hernia repair code 49561 (Repair initial incisional or ventral hernia; incarcerated or strangulated) to be part of partial colectomy code 44140 (Colectomy, partial; with anastomosis) because the hernia repair is integral to the closure. You may have to appeal for the additional money. So make sure the documentation supports the additional substantial complexity of the hernia repair and mesh implantation before appending modifier 22.

Bonus: Get exposure to ICD-10 coding equivalents.

Question: A mentally-challenged patient who delivered at home was admitted to the hospital for postpartum care. The patient delivered the placenta at home, and once admitted, she had no complications, but the ob-gyn did perform a first degree laceration repair. I’m not sure what diagnosis code to report. Should I look at routine postpartum care or pregnancy complications? And if I use a complication code, what would the fifth digit to a “1″ or “0?”

Texas Subscriber

Answer: Under most situations where the ob-gyn treated no problems during the admission, you would code V24.0 (Postpartum care and examination; immediately after delivery) on the admission date and V24.2 (Routine postpartum follow-up) for any subsequent routine care.

But in this case, your physician also repaired a first degree laceration (CPT code 59300, Episiotomy or vaginal repair, by other than attending physician). Therefore, you may consider this to be an admission for a postpartum condition and instead report 664.04 (First degree perineal laceration). The fifth digit cannot be “1″ or “0″ because the patient delivered prior to her admission and of course you know her delivery status. In this case, the fifth digit must be “4″ to indicate a purely postpartum condition. You may optionally report V24.0 and V24.2 as your secondary diagnoses, but they are not required in this case.

ICD-10: In the near future, you will replace ICD-9 codes V24.0 and V24.2 with ICD-10 codes Z39.0 (Encounter for care and examination of mother immediately after delivery) and Z39.2 (Encounter for routine postpartum follow-up), respectively. Code 664.04 will be replaced by O70.0 (First degree perineal laceration during delivery).

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Focus on form and drug to pinpoint the correct asthma supply code.

Are you clear on how to report asthma procedures and inhalers? Follow this advice, and you’ll breathe easy when it comes to asthma related claims.

Propellant-Driven Inhaler Falls Under 94664

If there’s confusion in your office over whether to use 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler, or IPPB device) to report education/training with the Advair diskus, look no further for your answer.

Code 94664s descriptor specifies demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device. Part of teaching the proper technique in using an inhaler (either propellant-driven [Advair Diskus] or dry powder) is to demonstrate and evaluate. In this respect, the code would seem appropriate to use for demonstration and evaluation, say sources with the Joint Council of Allergy, Asthma & Immunology.

The drawback: Not all payers will reimburse 94664. If practices abuse 94664, probably fewer payers will pay. To support reporting 94664, documentation should include an indication of medical necessity.

Clear Up Inhaler Code Confusion

Patients sometimes need multiple nebulizer treatments in the office to control acute asthma. If you’ve wondered whether to bill 94640 and J7613 multiple times, one time, or one time with modifiers for additional treatments, follow this advice and youll breathe easier.

Submit 94640 for Each Treatment

When a patient receives multiple aerosol treatments on the same date, you should use 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device]) for the first treatment.

Subsequent treatments will require modifier 76 (Repeat procedure by same physician), CPT says. Therefore, you would code three nebulizer treatments as:

• 94640 — First treatment
• 94640-76 x 2 — Two subsequent treatments.

A dose of coding: For the inhalation solution, report three units of J7613 (Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg). Because J7613 represents one unit dose, you should report per nebulizer treatment or, in our example, J7613 x 3.

E/M Might Also Be Acceptable

If the allergist meets the criteria, you should report the appropriate-level E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient …).

If the physician performs and documents a significant, separate E/M from the treatment (94640), append the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Time is a factor: If the asthma treatment lasted at least an hour, you’d code it with 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour). Report code 94640 for intermittent or one-time treatments.

Clue In to 5th Digit for Asthma Diagnosis

When you submit an asthma diagnosis, don’t forget that ICD-9 requires you to use a fifth-digit sub-classification with asthma codes (493.xx, Asthma). If you submit four digits for an asthma diagnosis, payers will probably reject the ICD-9 code as incomplete.

Correct method: Assign the fourth digit based on the asthma category:

• 493.0x, Extrinsic asthma
• 493.1x, Intrinsic asthma
• 493.2x, Chronic obstructive asthma
• 493.8x, Other forms of asthma
• 493.9x, Asthma, unspecified.

Then, identify the asthmas current state with the appropriate fifth digit:

• 0, unspecified
• 1, with status asthmaticus
• 2, with (acute) exacerbation.

For patients who do not have status asthmaticus or acute exacerbation, use a fifth digit of 0. Code 493.x0 is appropriate when the patients asthma is controlled. A final digit of 1 indicates that the patient has status asthmaticus, which is a medical emergency and is usually treated in the emergency department. You should assign a 2 when something has caused the condition to flare up.

Why it matters: Without this level of specificity, the payer may deny your claim for lack of medical necessity.

Example: An extrinsic asthma patient has an acute exacerbation that requires a nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device]). In this case, you should link 94640 to 493.02. Reporting a 2 as the fifth digit helps the payer understand why the patient needs the treatment. Without the final digit (or a fifth-digit of 0), the payer may assume that the patients asthma is under control, making the coded treatment unnecessary.

Reinstate Old J Codes to Get Claims Paid

If you flagged J7611-J7614 as invalid for CMS, you can green light the codes with a valid as of April 1, 2008, notation.

The spring-quarter updates to HCPCS 2008 deleted albuterol/levalbuterol codes J7602 (Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg [albuterol] or per 0.5 mg [levalbuterol]) and J7603 (& unit dose …). HCPCS reinstated:

• J7611 — Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg
• J7612 — Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 0.5 mg
• J7613 — Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg
• J7614 — Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg.

The CMS fee schedule Web site recognizes J7611-J7614 and not J7602-J7603.

Switch Back to Drug-Specific Codes

You may recall that CMS once replaced J7611-J7614 with Q4093 (Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg [albuterol] or per 0.5 mg [levalbuterol]) and Q4094 (& unit dose …)

Both Q4093 and Q4094 were deleted effective Jan. 1, 2008, however. HCPCS introduced new albuterol-levalbuterol combination codes J7602-J7603 to take the place of those deleted Q codes for 2008.
Medicare decided it was better to use the four codes that separated albuterol from levalbuterol, rather than the combined drug codes J7602-J7603.

Focus on 2 J7611-J7614 Factors

You can get the correct noncompounded solution supply code if you zoom in on two items:

• Form- concentrated (J7611, J7612) or unit dose (J7613, J7614).
• Drug- albuterol (J7611, J7613) or levalbuterol (J7612, J7614).