Section 20-2-IV - PROCEDURE CODE EXCEPTIONSA.Unlisted Procedure Codes. If a procedure is performed that is not listed in the Fee Schedule, the provider must bill with the appropriate "Unlisted Procedure" code and submit a narrative report to the payer explaining why it was medically necessary to use an unlisted procedure code. The CPT book contains codes for unlisted procedures. Use these codes only when there is no procedure code that accurately describes the service rendered. A report is required as these services are reimbursed by report (see below).
B.By Report (BR) Codes. By report (BR) codes are used by payers to determine the reimbursement for a service or procedure performed by the provider that does not have an established maximum allowable reimbursement allowance (MRA)(MAR). 1. Reimbursement for procedure codes listed as "BR" must be determined by the payer based on documentation submitted by the provider in a special report attached to the claim form. The required documentation to substantiate the medical necessity of a procedure does not warrant a separate fee. Information in this report must include, as appropriate: a. A complete description of the actual procedure or service performed;b. The amount of time necessary to complete the procedure or service performed;c. Accompanying documentation that describes the expertise and/or equipment required to complete the service or procedure.2. Reimbursement of "BR" procedures should be based on the usual and customary rate.C.Category II Codes. This Fee Schedule does not include Category II codes as published in the CPT book. Category II codes are supplemental tracking codes that can be used for performance measurements. These codes describe clinical components that are typically included and reimbursed in other services such as evaluation and management (E/M) or laboratory services. These codes do not have an associated fee.D.Category III Codes. This Fee Schedule does not include Category III codes published in the CPT bookmanual. If a provider bills a Category III code, payment may be denied.E.Add-On Codes. The CPT book identifies procedures that are always performed in addition to the primary procedure and designates them with a + symbol. Add-on codes are never reported for stand-alone services but are reported secondarily in addition to the primary procedure. Specific language is used to identify add on procedures such as "each additional" or "(List separately in addition to primary procedure)." The same physician or other qualified health care provider that performed the primary service/procedure must perform the add-on service/procedure. Add-on codes describe additional intra-service work associated with the primary service/procedure (e.g., additional digit(s), lesions(s), neurorrhaphy(s), vertebral segment(s), tendon(s), joint(s)).
Add-on codes are always performed in addition to the primary service/procedure, and must never be reported as a stand-alone code. All add-on codes found in the CPT book are exempt from the multiple procedure concept (see modifier 51 definition in this section). Add-on codes are reimbursed at one hundred percent (100%) of the maximum allowable reimbursement allowance or the provider's charge, whichever is less.
Refer to the most current version of the CPT book for a complete list of add-on codes.
F.Codes Exempt From Modifier 51 . This symbol Ø denotes procedure codes that are exempt from the use of modifier 51 and are not designated as add-on procedures/services as defined in the CPT book. Modifier 51 exempt services and procedures can be found in Appendix E of CPT 20162019. Additional codes that should not be subject to modifier 51 have been identified by Optum 360 based upon CPT guidelines and are included in this Fee Schedule using the B icon. Codes exempt from modifier 51 are reimbursed at one hundred percent (100%) of the maximum allowable reimbursement allowance or the provider's charge, whichever is less.
Moderate (Conscious) Sedation. To report moderate (conscious) sedation provided by the physician also performing the diagnostic or therapeutic service for which conscious sedation is being provided, see codes 99143-99145. It is not appropriate for the physician performing the sedation and the service for which the conscious sedation is being provided to report the sedation separately when the code is listed with the conscious sedation symbol K. The conscious sedation symbol identifies services that include moderate (conscious) sedation. A list of codes for services that include moderate (conscious) sedation is also included in the most current CPT book.
For procedures listed with K, when a second physician other than the health care professional performing the diagnostic or therapeutic services provides moderate (conscious) sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility), the second physician reports the associated moderate sedation procedure/service using codes 99148-99150.
Moderate sedation codes are not used to report minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care.