Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for code 77002 billed to the enrollee for October 19, 2022.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stating that Maximus did not apply the correct billing criteria. The Plan
demonstrated that the 2022 National Physician Fee Schedule shows code 77002 has a Global Days designation
of ZZZ. Per Medicare Claims Processing Manual Chapter 23, the designation of ZZZ means the code is related
to another service and is always included in the global period of the other service. Per Add-On Code Edits for
10012022: Add-On Code Edit Type - 1, Add-on code - 77002, Primary code - 20610. Per Medicare NCCI
Add-on Code Edits: An Add-on Code (AOC) is a Healthcare Common Procedure Coding System (HCPCS) /
Current Procedural Terminology (CPT) code that describes a service that is performed in conjunction with the
primary service by the same practitioner. An AOC is rarely eligible for payment if it's the only procedure
reported by a practitioner. Add-on codes may be identified in three ways:
1. The add-on code is in the AOC file as a Type 1, Type 2, or Type 3 AOC (formerly displayed as Type
I, Type II or Type III).
2. On the Medicare Physician Fee Schedule Database, an AOC generally has a global surgery period of
"ZZZ."
3. In the CPT Manual an add-on code is designated by the symbol "+."

The code descriptor of an AOC generally includes phrases such as "each additional" or "(List separately in
addition to primary procedure)."

CMS divided the AOCs into three types to distinguish the payment policy for each type: TYPE 1:
A Type 1 AOC has a limited number of identifiable primary procedure codes. The Change Request
(CR) lists the Type 1 AOCs with their acceptable primary procedure codes. A Type 1 AOC, with one
exception, is eligible for payment if one of the listed primary procedure codes is also eligible for
payment to the same practitioner for the same patient on the same date of service. Claims processing
contractors must adopt edits to assure that Type 1 AOCs are never paid unless a listed primary
procedure code is also paid. Per review of claim, the procedure code 77002, a type-I add-on code, was billed
with a valid primary procedure code 20610 on the same date of service. But this primary procedure code 20610
was denied due to incorrect billing as per CMS MUE guidelines and was not being appealed by the provider.
Per the above Medicare guidelines, a type-I add-on procedure code is paid only when the listed primary
procedure code is paid. So, the add-on procedure code 77002 is correctly denied as the primary
procedure code 20610 was denied. Therefore, the Plan has correctly denied the claim for payment.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the Plan has explained and provided the Medicare guidelines showing
code 77002 could not be paid as billed due to its payment being included in the primary code reported of
20610. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan
does not have to pay for code 77002 billed to the enrollee for October 19, 2022.