CurrentColorado Rocky Mountain Health PlansPolicy 2026R5012B

Add-on Code Reimbursement for Outpatient Facility Services

Defines UnitedHealthcare's reimbursement rules for CPT/HCPCS add-on codes billed on UB04 (or electronic equivalent) for outpatient hospitals, ASCs, and OSCs; applies to commercial and Individual Exchange plans and all network/non-network outpatient facility claims.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAdd-on Code Reimbursement for Outpatient Facility Services

Policy CodePolicy 2026R5012B

Change TypeNon‑material list maintenance

Effective Date

Next Review Date

Key ActionSubmit add-on codes only when billed with an appropriate reimbursed primary procedure and follow CMS I/OCE edits; infusion add-ons must appear on the same claim as the initial administration.

SourceLink

POLICY UPDATE CHANGES

Policy list changes/archival of Add-on to Primary Code Relationship List entries on multiple dates (most recently 4/19/2026).

All productsplan applicability

UB04/ASC/OSCforms & facility types

Allowedinfusion exception

Not reimbursedstand‑alone prohibition

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Add-on Code Coverage Criteria

Add-on code coverage criteria

Covered when ALL of the following criteria are met:

Add-on codes are reimbursed only when billed with an appropriate primary procedure code that is reimbursed.

Add-on services must be performed and reported by the same outpatient hospital reporting the primary service/procedure.

Infusion exception: For infusion services, add-on code date of service may differ from the initial drug administration date, provided both the initial drug service and the corresponding add-on code are reported on the same claim and only one initial drug administration is reported per distinct vascular access site per encounter.

Add-on codes billed as stand-alone codes (reported without an appropriate primary service/procedure by the same outpatient hospital) are not reimbursable.

Add-on to Primary Relationships & Reimbursement Rules

Infusion Add-on CPT CodesCPTCovered

96361	Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour (add-on)
96366	Intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour (add-on)
96367	Intravenous infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion (add-on)
96375	Infusion-related services (add-on)
96376	Infusion-related services, additional (add-on)
96409	Chemotherapy administration, IV push/bolus (primary)
96411	Chemotherapy infusion, additional (add-on)
96413	Chemotherapy infusion, primary (example primary codes listed)
96415	Chemotherapy infusion, additional (add-on)
96416	Chemotherapy infusion, additional (add-on)

1–10 of 13

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Add-on / Related Primary Examples & Rulesmixed

+ (CPT Add-on indicator)	Many add-on codes are designated by a leading '+' in CPT; see CPT Appendix D.
CMS Global Days = ZZZ	CMS assigns add-on codes a Global Days indicator of 'ZZZ' on the NPFS.
I/OCE	UnitedHealthcare follows CMS Integrated Outpatient Code Editor (I/OCE) edits for Type I add-on and primary relationships.

Reimbursement Dependency and Billing Rules

Add-on / primary dependencyAdd-on codes (e.g., 96361, 96366, 96367, 96375, 96376, 96411, 96415, 96416, 96417, 96423) are reimbursed only when billed in addition to an appropriate primary procedure that is reimbursed for the same outpatient hospital and is reported on the same day of service (or the day before).

Coding conventionsMany add-on CPT codes are indicated with a leading '+' in CPT and listed in CPT Appendix D; CMS may mark add-on codes with Global Days = 'ZZZ'.

I/OCE editsUnitedHealthcare follows CMS NCCI/I/OCE edits for Type I, II, III add-on relationships. If the add-on is not submitted same-day (or day-before) with the primary, it will not be reimbursed.

Never reimbursed aloneAdd-on codes should never be submitted or reimbursed without an appropriate reimbursed primary procedure; submission alone risks denial.

Claim Submission and Infusion-specific Guidance

Billing Rule

Submit add-ons only with a reimbursed primary; follow CMS I/OCE day-of-service edits

Submit add-on codes only when billed in conjunction with an appropriate reimbursed primary procedure. UnitedHealthcare follows CMS I/OCE edits for Type I add-on relationships — if an add-on code is not submitted on the claim as the same day of service or the day before, the add-on code will not be reimbursed. Add-on codes are never reimbursed unless a primary procedure code is also reimbursed.

Add-on codes must be performed by the same outpatient hospital reporting the primary service/procedure.
Add-on codes submitted on a different date than the primary will not be reimbursed except as noted for infusion services.

Billing Rule

Infusion: one initial administration per access; add-on and initial service must be on same claim

For infusion services, report only one initial drug administration per distinct vascular access site per encounter; other services via the same access are reported with sequential, concurrent, or additional hour codes. Add-on infusion codes need not have the same date of service as the initial drug administration, but both the initial drug service and the corresponding add-on code must be reported on the same claim.

One initial administration allowed per distinct vascular access site per encounter.
Initial drug service and add-on infusion code may be on different dates of service but must appear on the same claim.

Key Definitions

Add-on code rules

DefinitionAdd-on codes describe additional intra-service work associated with a primary procedure and are always reported in addition to the primary service/procedure.

Reporting requirementAdd-on codes must be reported in addition to the appropriate primary service and performed by the same outpatient hospital reporting the primary procedure.

Coverage stanceAdd-on codes are reimbursable when reported with an appropriate reimbursed primary service by the same outpatient hospital on the same date of service unless otherwise specified.

Stand‑alone code (not reimbursable)

Stand‑alone prohibitionAdd-on (stand-alone) codes reported without another appropriate primary service/procedure by the same outpatient hospital are not reimbursable.

Illustrative listInfusion add-on-to-primary relationships are maintained in the policy's relationship list (e.g., mappings shown on the Infusion Add-on to Primary Code Relationship List).

Policy alignmentStand-alone prohibition is consistent with CPT and CMS guidance referenced in the policy overview.