Probably not, but this will often be the case unless you routinely review payments for your add-on procedures.

Add-on procedure codes are available to allow the physician to charge for additional complexity or additional procedures which are related to, but not normally a part of, the primary procedure. Physicians' Current Procedural Terminology (CPT) contains more than 125 of these codes. The problem is that many, if not most, third party payers erroneously apply "multiple surgery pricing logic" to add-on procedures. The result is that you, the physician, receive less than a fair fee for your services.

What is multiple surgery pricing logic? Multiple surgery logic recognizes that it is inherently less expensive to perform several surgical procedures during one operative session than in several individual sessions. Third party payers typically reduce fees for secondary, tertiary, etc. procedures by 30 to 50 percent of their usual allowable fee for the same procedure performed by itself. Medicare has, in the past, reduced the second procedure by 50 percent, the third through fifth procedures by 75 percent and all beyond that were cut by 85 percent! This stringent rule penalized hand surgeons (performing multiple procedures on multiple digits) most of all, but Medicare wisely revised their policy this year.

Why is it important to apply multiple surgery logic to add-on procedures? Add on procedures are never performed or billed independently. In fact the CPT tells you for each add-on, "list separately in addition to code(s) for primary procedure" or "...each additional (lesion, interspace, cyst, 10% of body surface, nail, digit, etc)." Therefore, all relative value studies and all fee studies are predicated on the fact that add-ons are always performed in conjunction with another procedure and this is necessarily reflected in the value assigned to the add-on. In other words, the value or allowable free of every add-on has already been reduced. Thus it is inherently illogical to reduce add-ons as if they were secondary procedures.

Who pays add-ons correctly and who doesn't? To its credit, the Texas Medicare carrier has recognized the proper treatment of add-ons since it first implemented multiple surgery pricing logic. But Texas Medicaid only began paying add-ons at full value last June following strong protests and numerous appeals from our firm. All appeals on behalf of our clients for underpaid add-ons have now been paid by Medicaid. However a large number of other third party payers continue to underpay add-on codes.

Who is hurt the most by underpayment of add-ons? In our experience, the cardiovascular surgeons are hardest hit followed closely by the orthopedists. Not only do these specialties have a great many add-on procedures but the add-ons are also quite high in value. The adjacent table provides the most common add-ons for these and other specialties.

How can you be sure to receive full value for your add-ons?

• First, thoroughly familiarize yourself with add-ons in your specialty.
• Second, mail or fax your list of add-ons to your managed care plans and major indemnity insurers asking them for contract or allowable fees.
• Third, once you have these fees, instruct your staff to monitor all payments for add-ons which are incorrectly reduced.
• Fourth, challenge any incorrectly reduced add-ons. Appeal by phone or in writing.
• Fifth, if the appeal taker cannot understand the basis for your appeal, send your appeal to the plan's medical director. You might even want to include a copy of this article. Alternatively you can retain a competent billing service to do all of the above for you.