Description 

Add-on codes are those additional intra-services carried out in addition to the primary procedure. They can be found in Appendix D of the CPT® book and typically have designations of “+” symbol throughout the CPT® manual. Similarly, add-on codes for HCPCS codes are noted in the manual with the following: “list separately in addition to code for primary procedure” or “each additional”. Add-on codes are reimbursable services when reported in addition to the appropriate primary service by the same provider or same group practice on the same date of service unless otherwise specified within the policy. Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse add-on services according to the criteria outlined in this policy.

Reimbursement Guidelines

When submitting an add-on code, a primary code must also be submitted. Add-on codes submitted as stand-alone procedures are not eligible for reimbursement.

Add-on codes are not eligible for reimbursement unless the primary procedure submitted by the same provider or same group practice is reimbursable on the same date of service.

Add-on codes appended with Modifier 51 are not eligible for reimbursement.

Exceptions to same date of service requirement:

Labor epidural add-on codes require a base code presence on the same day or the day prior.

Facility IV infusion add-on codes require a base code presence on the same day or within two (2) days prior.

Rationale

Blue Cross NC will reimburse add-on services when correct coding guidelines are followed as defined by the AMA, ADA, and CMS.

In alignment with AMA, Modifier 51 (multiple procedures) should not be appended to any add-on code as the intent behind an add-on code already encompasses the reduced service.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related policy

Bundling Guidelines

Modifier Guidelines

References

American Medical Association, Current Procedural Terminology (CPT®)

Centers for Medicare & Medicaid Services, CMS Manual System, Medicare Claims Processing Manual 100-04, and NCCI Policy Manual

Healthcare Common Procedure Coding System

History

6/1/2022 New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 Routine Policy Review. Minor Revisions Only. (cjw)

11/1/2024 Clarification to the definition of same group practice. No change to policy intent. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area).

This policy does not apply to Blue Cross NC members who seek care in other states. This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.