August 2009
Billing add-on codes and Modifier -59
Add-on codes describe services performed in addition to
the primary procedure and are not valid as stand-alone codes. Regence
will deny reimbursement for an add-on procedure code as a Regence
Correct Code Editor (CCE) (PDF) when its primary procedure code
is denied as part of CMS' National
Correct Coding Initiative (NCCI) or a CCE code pair.
For example:
Primary code: CPT 15220 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less
Primary code: CPT 13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm
Add-on code: CPT 13122 each additional 5 cm or less (List separately in addition to code for primary procedure)
The primary code, CPT 13121, will deny as an NCCI code pair denial when billed with CPT 15220. Therefore, the add-on code CPT 13122 will be denied as a Regence CCE code pair denial when billed with CPT 15220.
When the primary code is submitted with Modifier -59 to indicate a separately identifiable procedure, the add-on code must also be submitted with Modifier -59. If CPT 13121 and 13122 meet the established criteria for Modifier -59 use, then Modifier -59 must be billed with both codes to bypass the code pair denials.