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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare guidance says, "CPT Code 88341 Global Days  ZZZ." You can find this guidance in the 2022 
National Physician Fee Schedule Relative Value File April Release. 
 
Medicare guidance says "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 ts the 
only procedure reported by a practitioner. Add-on codes may be identified in three ways: The code is listed in 
this CR or subsequent ones as a Type I, Type II, or Type III add-on code. On the Medicare Physician Fee 
Schedule Database an add-on code generally has a global surgery period of "ZZZ". In the CPT Manual an add-
on code is designated by the symbol "+". The code descriptor of an add-on code generally includes phrases 
such as "each additional" or "(List separately in addition to primary procedure)." CMS has divided the add-on 
codes into three groups to distinguish the payment policy for each type. 1. Type I - 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 1AOC, 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. Final Complete File of Add-on Code Edits for October 
01, 2022, Implementation for Medicare, Type I  CPT Manual, HCPCS Manual, and/or CMS Policy defines all 
acceptable primary codes." You can find this guidance in the CMS.GOV Add-on Code Edits.  
 
Medicare guidance says, "For Add-on code 88341 appropriate Primary Code 88342." You can find this 
guidance in the Add-On Code Edits list. 
 
Medicare guidance says "Field Name & Description - Global Surgery-This field provides the postoperative 
time frames that apply to payment for each surgical procedure or another indicator that describes the 
applicability of the global concept to the service. ZZZ = Code related to another service and is always included 
in the global period of the other service. (Note: Physician work is associated with intra-service time and in some instances the post service time.)." You can find this guidance in the Medicare Claims Processing Manual 
Chapter 23 - Fee Schedule Administration and Coding Requirements, Section 50.6 Physician Fee Schedule 
Payment Policy Indicator File Record Layout. 
 
The Medicare guidelines say "PTP edits with a CCMI of 1: On appeal, if the correct coding initiative edit 
modifier indicator is a 1, the reviewer must determine whether the claim was coded correctly. For example, 
the reviewer should determine whether the provider or supplier reported an incorrect code, a medically 
unnecessary service, or simply neglected to use a modifier. The reviewer may change the initial determination 
only if the correct coding initiative edit has a modifier indicator of 1 and the reviewer determines that an 
NCCI-associated modifier could have been appended to either code of a correctly coded edit code pair. If the 
reviewer determines that the claim was coded incorrectly then, the review determination must repeat the 
generic language that appears in the Medicare Summary Notice (MSN) or remittance advice notice pertaining 
to the NCCI edit. In addition, MACs must include the more detailed explanation of the NCCI edit, which can 
be found in the standard correspondence language for MACs in the Correspondence Language Manual for 
Medicare Services." You can find this guidance in the Medicare Claims Processing Manual, Chapter 23 - Fee 
Schedule Administration and Coding Requirements, Section 20.9.3.1. 
 
The Medicare guidelines say "The A/B MACs (A) must provide a listing of the required data elements, 
including a brief explanation to providers and suppliers. A/B MACs (A) must educate providers regarding the 
distinction between submissions which are not considered claims, but which are returned to provider (RTP) and 
submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted 
as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected 
on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected 
and resubmitted." You can find this guidance in the Medicare Claims Processing Manual Chapter 1 - General 
Billing Requirements Section 70.2.3.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.