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Add-on Codes to Require Use of Appropriate Base Procedure Code

November 21, 2019

To: All Providers

Beginning on March 1, 2020, we will only reimburse for add-on codes attached to a designated primary service or appropriate base procedure code.

While we have allowed these codes to pay in the past, with the implementation of the ClaimsXten clinical editor we are able to better align our claims processing requirements with standard coding guidelines, including those for billing add-on code rules.

Our clinical editor will begin denying claim lines containing CPT or HCPCS add-on codes that are billed without the presence of one or more related primary service (base) procedure codes on March 1.

The CPT Manual designates add-on codes with the “+” symbol. Code descriptors for add-on codes generally include phrases such as “each additional” or “list separately in addition to primary procedure.”

In addition to requiring a base code, add-on codes should only be billed:

  • For the same patient
  • By the same provider
  • For the same date of service associated with the same base code

Miscoding Examples

Vaccine administration and therapeutic and diagnostic injection codes are often miscoded, and will be denied when they are submitted alone or without the correct primary or applicable drug code.

A few examples are below:

  • J3420 (vitamin injection) cannot be billed alone or as an add-on code to procedure code 90471 (immunization administration - percutaneous, intradermal, subcutaneous or intramuscular - of one vaccine) since it is not a vaccine.
    • J3420 should be billed as an add-on code to 96372 (therapeutic, prophylactic, or diagnostic injection - subcutaneous or intramuscular)
  • 90732 (Pneumococcal polysaccharide vaccine) can be billed as an add-on code to procedure code 90471 (immunization administration), but NOT as an add-on code to 96372 (therapeutic, prophylactic or diagnostic injection)

Click below for more information from CMS about the use of add-on codes.

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