Description
CMS has designated certain codes as "add-on procedures". These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also billed. Clinical Laboratory providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied.
Affected Code(s)
81266, 81265, 81416, 81415, 81426, 81425, 81536, 81535, 82952, 82951, 86826, 86825, 87187, 87186, 87188, 87503, 87502, 87904, 87903, 88155, 88142-88154, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164-88167, 88174, 88175, 88177, 88172, 88185, 88184, 88314, 17311-17315, 88302-88309, 88329-88334, 88341, 88342, 88350, 88346, 88364, 88365, 88369, 88368, 88373, 88367, 88388
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930 – Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual Chapter 01- General Billing Requirements, §70- Time Limitations for Filing Part A and Part B Claims
8. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.D- Coding Services Supplemental to Principal Procedure (Add-On Codes) Code
9. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, §40.8- Date of Service (DOS) for Clinical Laboratory and Pathology Specimens
10. Medicare Claims Processing Manual, Chapter 29- Appeals of Claim Decisions, §240- Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals
11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6
12. National Correct Coding Initiative, Add-on Code Edits https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits
13. AMA CPT Codebook