Add-on Codes Policy, Professional...Medicare Advantage reimbursement policies use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS), or other

UnitedHealthcare® Medicare Advantage

Reimbursement Policy CMS 1500

2019R9007E

Proprietary information of UnitedHealthcare Medicare Advantage. Copyright 2019 United HealthCare Services, Inc. 2019R9007E

Add-on Codes Policy, Professional

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates. You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Medicare Advantage reimbursement policies use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms (CMS 1450). Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general resource regarding UnitedHealthcare's Medicare Advantage reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Medicare Advantage may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Medicare Advantage enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, and/or the enrollee's benefit coverage documents**. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Medicare Advantage due to programming or other constraints; however, UnitedHealthcare Medicare Advantage strives to minimize these variations. UnitedHealthcare Medicare Advantage may modify this reimbursement policy at any time to comply with changes in CMS policy and other national standard coding guidelines by publishing a new version of the reimbursement policy on this website. However, the information presented in this reimbursement policy is accurate and current as of the date of publication. UnitedHealthcare Medicare Advantage encourages physicians and other health care professionals to keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier website regularly. Physicians and other health care professionals can sign up for regular distributions for policy or regulatory changes directly from CMS and/or your local carrier. UnitedHealthcare's Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements. *CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. ** For more information on a specific enrollee's benefit coverage, please call the customer service number on the back of the member ID card. Application This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.

Policy

Overview

Add-on codes are reimbursable services when reported in addition to the appropriate primary service by the Same Individual Physician or Other Qualified Health Care Professional on the same date of service unless otherwise specified within the policy. Add-on codes reported as Stand-alone codes are not reimbursable services in accordance with Current Procedural Terminology (CPT®) and the Centers for Medicare and Medicaid Services (CMS) guidelines.



2019R9007E


For the purpose of this policy, the Same Individual Physician or Other Qualified Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number.

Reimbursement Guidelines

The basis for Add-on codes is to enable physicians or other qualified health care professionals to separately identify a service that is performed in certain situations as an additional service or a commonly performed supplemental service complementary to the primary service/procedure. UnitedHealthcare Medicare Advantage follows the American Medical Association (AMA) and CMS with respect to the reporting of "Add-on" CPT and HCPCS codes. Per CPT Add-on codes describe additional intra-service work associated with a primary procedure/service, are always reported in addition to the primary service/procedure, and must be performed by the Same Individual Physician or Other Qualified Health Care Professional reporting the primary service/procedure. Many add-on codes are designated by the AMA with a "+" symbol and are also listed in Appendix D of the CPT book. CMS assigns Add-on codes a Global Days indicator of "ZZZ" on the CMS National Physician Fee Schedule (NPFS). CMS has divided the add-on codes into three groups, Type I, Type II, and Type III to distinguish the payment policy for each group. In some instances, a Definitive Source specifies the primary procedure/service codes that must be reported in conjunction with a given Add-on code. In other situations, a primary/add-on code relationship may exist but the guidance from CPT or CMS is not as well-defined. Specifically, the code description does not directly identify the Add-on code or identify any specific primary codes that correspond with that code. In those instances an Interpretive Source is necessary utilizing CPT, CMS and/or specialty society guidelines. UnitedHealthcare Medicare Advantage will interpret these sources to identify additional primary/add-on relationships. For these code pairs, UnitedHealthcare Medicare Advantage also requires that the Add-on code must be reported with a given primary procedure/service code. In addition, add-on codes are never reimbursed unless a primary procedure code is also reimbursed. Please see the Definitions section below for further explanations of Definitive and Interpretive Sources. Key phrases to identify Add-on codes when not specified in the code description, include, but are not limited to, the following:

list separately in addition to; and each additional; and done at time of other major procedure.

CMS will update the list of add-on codes with the primary procedure codes on an annual basis and the changes will be based on the changes made to the CPT Manual or HCPCS Level II Manual. Quarterly changes may also be posted as appropriate. Critical Care Services (CPT Codes 99291, +99292) Critical care codes are time based Evaluation and Management (E/M) services. CPT code 99291 is reported for the first 30-74 minutes of care; Add-on code +99292 is reported for each additional 30 minutes. UnitedHealthcare Medicare Advantage will reimburse for critical care add-on services (code +99292) in the following situations:

The Same Individual Physician or Other Qualified Health Care professional reporting provides more than 74 minutes, thus submitting Add-on code +99292 indicating each additional 30 minutes of care beyond the first 74 minutes.

The Same Specialty Physician or Other Qualified Health Care Professional each supplying critical care services

for the same patient on the same date of service may report using one of the following methods:

o The primary code 99291 is reported by the Physician or Other Qualified Health Care Professional that provides the first 30-74 minutes of critical care. The Add-on code +99292 is reported for each additional



2019R9007E


30 minutes of care beyond the first 74 minutes of critical care when provided by the Same Specialty Physician or Other Qualified Health Care Professional.

o A single physician may report all critical care service codes on behalf of the other members within the same group/same specialty.

The Same Group Physician and/or Other Qualified Health Care Professionals each supplying critical care services for the same patient on the same date of service would each individually report their own critical care services. For example, two physicians within the same provider group, but of different specialties each provide critical care services for the same patient on the same date of service. Because the physicians are of different specialties, each would report their critical care services separately. Both physicians may individually report code 99291, and +99292 for each additional 30 minutes of critical care services depending of the length of services provided by each physician.

Definitions

Add-on code Add-on codes describe additional intra-service work associated with the primary service/procedure.

Definitive Source Definitive Sources contain the exact codes, modifiers or very specific instructions from the given source.

Interpretive Source An edit source that includes guidelines; however, no exact or specific code or modifier information is listed. Therefore, an interpretation must be made as to what codes correlate to the guidelines. Additionally, an interpretation may be applied to surrounding or similar codes based on related definitively sourced edits.

Same Group Physician and/or Other Qualified Health Care Professional

All physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number.

Same Individual Physician or Other Qualified Health Care Professional

The same individual rendering health care services reporting the same Federal Tax Identification number.

Same Specialty Physician or Other Qualified Health Care Professional

Physicians and/or other qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.

Stand-alone code A code reported without another primary service/procedure code by the Same Individual Physician or other qualified health care professional.

Questions and Answers

1

Q: How would the policy handle the billing of codes 13102 (Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) and 13100 (Repair, complex, trunk; 1.1 cm to 2.5 cm) on the same date of service, by the same physician? A: In accordance with CPT guidelines, Add-on code 13102 is to be used in conjunction with code 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) only. Therefore, code 13102 reported without the appropriate primary code, 13101 will not be separately reimbursed.

2 Q: How has UnitedHealthcare Medicare Advantage determined which codes are "Add-on" codes that must be reported with a primary service? A: The policy follows CPT guidelines for those codes designated with a "+" symbol. These codes are considered to be an Add-on code by UnitedHealthcare Medicare Advantage.

3 Q: Does UnitedHealthcare Medicare Advantage require the Add-on code be submitted on the same claim as the



2019R9007E


primary code?

A: No. The Add-on code may be reported on a separate claim submission from the primary code; however it is recommended the Add-on and primary procedure codes be reported on the same claim form.

4 Q: On the Medicare Physician Fee Schedule Status Indicator Policy there are codes marked with a global indicator of ZZZ. Does this mean that it is an add-on code? A: Yes, ZZZ is an indicator that it is an add-on code. Example: Code 13102 has a ZZZ listed for global days.

Attachments

AddOn to Primary Codes List_2019E

This table includes Add-on codes which will only be reimbursed when reported with the appropriate primary code.

Resources

www.cms.gov CMS NCCI Add-On Code Edits CMS Claims Processing Manual and other CMS publications and resources AMA Current Procedural Terminology (CPT®*) manual

History 7/10/2019 Policy Version Change

• Add-on to Primary Code Relationship list update • Definition statement added to the Overview section

6/5/2019 Policy Version Change • Add-on to Primary Code Relationship list update

5/3/2019 Annual Anniversary Date (no new version) 4/1/2019 Policy Version Change

• Add-on to Primary Code Relationship list update • Template change • Archived history prior to 4/1/17

1/17/2019 Policy Version Change • Add-on to Primary Code Relationship list update

1/1/2019 Policy Version Change • Add-on to Primary Code Relationship List update

9/7/2018 Policy Version Change • Policy number changed to 2018R9007A • Title change to add Professional • Archive history prior to 9/1/2016

7/11/2018 Annual Review (no new version) • Archive history prior to 1/1/2016

5/8/2018 Policy Version Change • Preamble updated • Verbiage change • Critical Care language added
http://www.cms.gov/https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html

Add-on Code

Primary Code

0054T 228400054T 228420054T 228430054T 228440054T 271200054T 271220054T 271250054T 271300054T 271320054T 271340054T 271370054T 271380054T 271400054T 271460054T 271470054T 271510054T 271560054T 271580054T 271610054T 271650054T 271700054T 271750054T 271760054T 271770054T 271780054T 271790054T 271810054T 271850054T 271870054T 272000054T 272020054T 272150054T 272160054T 272170054T 272180054T 272200054T 272220054T 272260054T 272270054T 272280054T 272300054T 272320054T 272350054T 272360054T 272380054T 272400054T 272440054T 272450054T 27246

0054T 272480054T 272500054T 272520054T 272530054T 272540054T 272560054T 272570054T 272580054T 272590054T 272650054T 272660054T 272670054T 272680054T 272690054T 274050054T 274070054T 274090054T 274370054T 274380054T 274400054T 274410054T 274420054T 274430054T 274450054T 274460054T 274470054T 274480054T 274500054T 274540054T 274550054T 274570054T 274650054T 274660054T 274680054T 274700054T 274720054T 274750054T 274770054T 274790054T 274850054T 274860054T 274870054T 275000054T 275010054T 275020054T 275030054T 275060054T 275070054T 275080054T 275090054T 27510

0055T 275560055T 275570055T 275580055T 275600055T 275620055T 275660055T 277050055T 277070055T 277090055T 277120055T 277150055T 277200055T 277220055T 277240055T 277250055T 298500055T 298510055T 298550055T 298560055T 298880055T 298890071U 0070U0072U 0070U0073U 0070U0074U 0070U0075U 0070U0076T 0075T0076U 0070U0095T 228640098T 228610163T 228570164T 228650165T 228620174T 710450174T 710460174T 710470174T 7104801953 0195201968 0196701969 019670205T 929200205T 929240205T 929280205T 929330205T 929370205T 929410205T 929430205T 929750205T 934540205T 934550205T 93456

0205T 934570205T 934580205T 934590205T 934600205T 934610205T 935630205T 935640214T 0213T0215T 0213T0215T 0214T0217T 0216T0218T 0216T0218T 0217T0222T 0219T0222T 0220T0222T 0221T0229T 0228T0231T 0230T0290T 657100290T 657300290T 657500290T 657550376T 0191T0396T 274450396T 274460396T 274470396T 274860396T 274870396T 274880397T 432600397T 432610397T 432620397T 432630397T 432640397T 432650397T 432740397T 432750397T 432760397T 432770397T 432780399T 933030399T 933040399T 933060399T 933070399T 933080399T 933120399T 933140399T 933150399T 933170399T 933500399T 93351

0437T 588050437T 588220437T 589510437T 589520437T 589530437T 589560437T 589570437T 589600437T 591000437T 591200437T 591300437T 593250439T 933060439T 933070439T 933080439T 933500439T 933510443T 557000450T 0449T0466T 645680471T 0470T0480T 0479T0482T 784910482T 784920492T 0491T0496T 0495T0513T 0512T0514T 669820514T 669840523T 934540523T 934550523T 934560523T 934570523T 934580523T 934590523T 934600523T 934610560T 0559T0562T 0561T10004 1002110006 1000510008 1000710010 1000910012 1001110036 1003511001 1100011008 1018011008 1100411008 1100511008 1100611045 11042

11046 1104311047 1104411103 1110211103 1110411103 1110611105 1110411105 1110611107 1110611201 1120011732 1173011922 1192113102 1310113122 1312113133 1313213153 1315214302 1430115003 1500215005 1500415101 1510015111 1511015116 1511515121 1512015131 1513015136 1513515151 1515015152 1515115156 1515515157 1515615201 1520015221 1522015241 1524015261 1526015272 1527115274 1527315276 1527515278 1527715777 1197015777 1316015777 1500215777 1500415777 1504015777 1505015777 1510015777 1511015777 1511515777 1512015777 1513015777 1513515777 1515015777 1515515777 15200

15777 1522015777 1524015777 1526015777 1527115777 1527315777 1527515777 1527715777 1573415777 1931615777 1931815777 1932415777 1932515777 1932815777 1933015777 1934015777 1934215777 1935015777 1935515777 1935715777 1936115777 1936415777 1936615777 1936715777 1936815777 1936915777 1937015777 1937115777 1938015777 1939615777 S206615777 S206715777 S206815787 1578615847 1583016036 1603517003 1700017312 1731117314 1731317315 1731117315 1731217315 1731317315 1731419001 1900019082 1908119084 1908319086 1908519126 1912519282 1928119284 1928319286 1928519288 19287

19294 1930119294 1930219297 1930119297 1930220930 2231920930 2253220930 2253320930 2254820930 2255120930 2255220930 2255420930 2255620930 2255820930 2259020930 2259520930 2260020930 2261020930 2261220930 2263020930 2263320930 2263420930 2280020930 2280220930 2280420930 2280820930 2281020930 2281220931 2231920931 2253220931 2253320931 2254820931 2255120931 2255220931 2255420931 2255620931 2255820931 2259020931 2259520931 2260020931 2261020931 2261220931 2263020931 2263320931 2263420931 2280020931 2280220931 2280420931 2280820931 2281020931 2281220932 23210

20932 2322020932 2415020932 2517020932 2707520932 2707620932 2707720932 2736520932 2764520932 2770420933 2321020933 2322020933 2415020933 2517020933 2707520933 2707620933 2707720933 2736520933 2764520933 2770420934 2321020934 2322020934 2415020934 2517020934 2707520934 2707620934 2707720934 2736520934 2764520934 2770420936 2231920936 2253220936 2253320936 2254820936 2255120936 2255220936 2255420936 2255620936 2255820936 2259020936 2259520936 2260020936 2261020936 2261220936 2263020936 2263320936 2263420936 2280020936 2280220936 2280420936 2280820936 22810

20936 2281220937 0219T20937 0220T20937 0221T20937 2231920937 2253220937 2253320937 2254820937 2255120937 2255220937 2255420937 2255620937 2255820937 2259020937 2259520937 2260020937 2261020937 2261220937 2263020937 2263320937 2263420937 2280020937 2280220937 2280420937 2280820937 2281020937 2281220938 0219T20938 0220T20938 0221T20938 2231920938 2253220938 2253320938 2254820938 2255120938 2255220938 2255420938 2255620938 2255820938 2259020938 2259520938 2260020938 2261020938 2261220938 2263020938 2263320938 2263420938 2280020938 2280220938 2280420938 22808

20938 2281020938 2281220939 2231920939 2253220939 2253320939 2253420939 2254820939 2255120939 2255220939 2255420939 2255620939 2255820939 2259020939 2259520939 2260020939 2261020939 2261220939 2263020939 2263320939 2263420939 2280020939 2280220939 2280420939 2280820939 2281020939 2281220985 2284020985 2284220985 2284320985 2284420985 2712020985 2712220985 2712520985 2713020985 2713220985 2713420985 2713720985 2713820985 2714020985 2714620985 2714720985 2715120985 2715620985 2715820985 2716120985 2716520985 2717020985 2717520985 2717620985 2717720985 27178

20985 2717920985 2718120985 2718520985 2718720985 2720020985 2720220985 2721520985 2721620985 2721720985 2721820985 2722020985 2722220985 2722620985 2722720985 2722820985 2723020985 2723220985 2723520985 2723620985 2723820985 2724020985 2724420985 2724520985 2724620985 2724820985 2725020985 2725220985 2725320985 2725420985 2725620985 2725720985 2725820985 2725920985 2726520985 2726620985 2740520985 2740720985 2740920985 2743720985 2743820985 2744020985 2744120985 2744220985 2744320985 2744520985 2744620985 2744720985 2744820985 2745020985 2745420985 27455

20985 2745720985 2746520985 2746620985 2746820985 2747020985 2747220985 2747520985 2747720985 2747920985 2748520985 2748620985 2748720985 2750020985 2750120985 2750220985 2750320985 2750620985 2750720985 2750820985 2750920985 2751020985 2751120985 2751320985 2751420985 2751620985 2751720985 2751920985 2752020985 2752420985 2753020985 2753220985 2753520985 2753620985 2753820985 2754020985 2755020985 2755220985 2755620985 2755720985 2755820985 2756020985 2756220985 2756620985 2770520985 2770720985 2770920985 2771220985 2771520985 2772020985 2772220985 27724

20985 2772520985 2985020985 2985120985 2985520985 2985620985 2988820985 2988922103 2210022103 2210122103 2210222116 2211022116 2211222116 2211422208 2220622208 2220722216 2221022216 2221222216 2221422226 2222022226 2222222226 2222422328 2232522328 2232622328 2232722512 2251022512 2251122515 2251322515 2251422527 2252622534 2253222534 2253322552 2255122585 2255422585 2255622585 2255822614 2260022614 2261022614 2261222614 2263022614 2263222614 2263322632 2261222632 2261422632 2263022632 2263322632 2263422634 2261222634 2261422634 2263022634 2263222634 22633

22840 2210022840 2210122840 2210222840 2211022840 2211222840 2211422840 2220622840 2220722840 2221022840 2221222840 2221422840 2222022840 2222222840 2222422840 2231022840 2231522840 2231822840 2231922840 2232522840 2232622840 2232722840 2253222840 2253322840 2254822840 2255122840 2255222840 2255422840 2255622840 2255822840 2259022840 2259522840 2260022840 2261022840 2261222840 2263022840 2263322840 2263422840 2280022840 2280222840 2280422840 2280822840 2281022840 2281222840 6300122840 6300322840 6300522840 6301122840 6301222840 6301522840 6301622840 63017

22840 6302022840 6303022840 6304022840 6304222840 6304522840 6304622840 6304722840 6305022840 6305122840 6305522840 6305622840 6306422840 6307522840 6307722840 6308122840 6308522840 6308722840 6309022840 6310122840 6310222840 6317022840 6317222840 6317322840 6318022840 6318222840 6318522840 6319022840 6319122840 6319422840 6319522840 6319622840 6319722840 6319822840 6319922840 6320022840 6325022840 6325122840 6325222840 6326522840 6326622840 6326722840 6326822840 6327022840 6327122840 6327222840 6327322840 6327522840 6327622840 6327722840 6327822840 63280

22840 6328122840 6328222840 6328322840 6328522840 6328622840 6328722840 6329022840 6330022840 6330122840 6330222840 6330322840 6330422840 6330522840 6330622840 6330722841 2210022841 2210122841 2210222841 2211022841 2211222841 2211422841 2220622841 2220722841 2221022841 2221222841 2221422841 2222022841 2222222841 2222422841 2231022841 2231522841 2231822841 2231922841 2232522841 2232622841 2232722841 2253222841 2253322841 2254822841 2255122841 2255222841 2255422841 2255622841 2255822841 2259022841 2259522841 2260022841 2261022841 2261222841 2263022841 22633

22841 2263422841 2280022841 2280222841 2280422841 2280822841 2281022841 2281222841 6300122841 6300322841 6300522841 6301122841 6301222841 6301522841 6301622841 6301722841 6302022841 6303022841 6304022841 6304222841 6304522841 6304622841 6304722841 6305022841 6305122841 6305522841 6305622841 6306422841 6307522841 6307722841 6308122841 6308522841 6308722841 6309022841 6310122841 6310222841 6317022841 6317222841 6317322841 6318022841 6318222841 6318522841 6319022841 6319122841 6319422841 6319522841 6319622841 6319722841 6319822841 6319922841 6320022841 63250

22841 6325122841 6325222841 6326522841 6326622841 6326722841 6326822841 6327022841 6327122841 6327222841 6327322841 6327522841 6327622841 6327722841 6327822841 6328022841 6328122841 6328222841 6328322841 6328522841 6328622841 6328722841 6329022841 6330022841 6330122841 6330222841 6330322841 6330422841 6330522841 6330622841 6330722842 2210022842 2210122842 2210222842 2211022842 2211222842 2211422842 2220622842 2220722842 2221022842 2221222842 2221422842 2222022842 2222222842 2222422842 2231022842 2231522842 2231822842 2231922842 2232522842 2232622842 22327

22842 2253222842 2253322842 2254822842 2255122842 2255222842 2255422842 2255622842 2255822842 2259022842 2259522842 2260022842 2261022842 2261222842 2263022842 2263322842 2263422842 2280022842 2280222842 2280422842 2280822842 2281022842 2281222842 6300122842 6300322842 6300522842 6301122842 6301222842 6301522842 6301622842 6301722842 6302022842 6303022842 6304022842 6304222842 6304522842 6304622842 6304722842 6305022842 6305122842 6305522842 6305622842 6306422842 6307522842 6307722842 6308122842 6308522842 6308722842 6309022842 6310122842 6310222842 63170

22842 6317222842 6317322842 6318022842 6318222842 6318522842 6319022842 6319122842 6319422842 6319522842 6319622842 6319722842 6319822842 6319922842 6320022842 6325022842 6325122842 6325222842 6326522842 6326622842 6326722842 6326822842 6327022842 6327122842 6327222842 6327322842 6327522842 6327622842 6327722842 6327822842 6328022842 6328122842 6328222842 6328322842 6328522842 6328622842 6328722842 6329022842 6330022842 6330122842 6330222842 6330322842 6330422842 6330522842 6330622842 6330722843 2210022843 2210122843 2210222843 2211022843 2211222843 22114

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Add-on Codes Policy, Professional...Medicare Advantage reimbursement policies use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS), or other