CurrentMolina HealthcarePolicy N/A

Add-on code reimbursement

Defines Molina Healthcare's reimbursement stance and billing guidance for CPT add-on codes, including examples and group practice billing rules; applies to Molina providers submitting claims under state and federal programs.

Policy Summary

PayerMolina Healthcare

PolicyAdd-on code reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen billing an add-on without the primary procedure, ensure the primary is billed by a provider of the same specialty in the same group practice.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

examples updatedexamples updated

11/20/2020initial creation

12/12/2024most recent example update

Add-on code coverage and billing criteria

Covered/paid as permitted by the member benefit document and applicable law. The following reimbursement and billing constraints apply to CPT add‑on codes.

Policy Summary

PayerMolina Healthcare

PolicyAdd-on code reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen billing an add-on without the primary procedure, ensure the primary is billed by a provider of the same specialty in the same group practice.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Add‑on codes are identified using CMS and CPT indicators (eg, 'ZZZ' in MPFS global surgery period column or '+' in the CPT manual).
See coding references for identification of add‑on codes.
Listing of a code in this policy does not guarantee coverage; coverage is determined by the member's benefit document and applicable federal/state law and contracts.

ALL of the following

When an add‑on code is billed without the primary procedure, the primary procedure must be billed by a provider of the same specialty in the same group practice.
ANY of the following
- Critical care: only one physician of the same specialty in the same group may report the initial critical care procedure (99291) on the same date; other physicians in that same specialty/group on that date must report the add‑on (99292).
- Anesthesia (Medicaid and Marketplace examples): one provider may report 01967 and another provider in the same group may report 01968 on the same date when applicable.

ALL of the following

Providers must follow industry standard coding practices and Molina will monitor compliance and take corrective action for noncompliance, including claim denial or recovery where appropriate.
Codes listed are for reference only and may not be all‑inclusive; deleted or inactive codes may not be eligible for reimbursement.
In case of conflict, federal/state guidance and the provider contract prevail over this policy.

Operational note

Providers should verify coverage and billing requirements against the member benefit document and applicable state/federal rules prior to billing. Molina reserves the right to revise this policy as industry practices change.

Add-on code identification and examples

Referenced add-on indicators and example CPT codesCPT

ZZZ	CMS value indicating add-on codes in global surgery period column of MPFS
+	CPT Manual symbol indicative of add-on codes
58110	Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure)
88341	Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure
99292	Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes
99291	Initial critical care service (used as the primary when 99292 is an add-on)
01968	Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia
01967	Neuraxial labor analgesia/anesthesia for planned vaginal delivery

Add-on identification

MPFS add-on indicatorIdentified by the value 'ZZZ' in the global surgery period column of the Medicare Physician Fee Schedule (MPFS)

CPT Manual add-on symbolIndicated by the '+' symbol in the CPT Manual

Scope of identificationThese indicators are used to recognize add-on codes for billing and reimbursement reference

Billing constraints and provider billing rules

Billing Rule

Group-practice billing constraints for add-on codes

Add-on codes may be billed without the primary procedure only in two specified circumstances, and when this occurs the primary procedure must be billed by a provider of the same specialty in the same group practice. For critical care, on the same date of service only one physician of the same specialty in the group may report the initial critical care code 99291 (with or without 99292); other physician(s) must report their critical care services with add-on code 99292. For anesthesia related to cesarean delivery, for Medicaid and Marketplace services one anesthesia provider may report 01967 and another anesthesia provider in the same group practice may report 01968.

Primary procedure must be billed by a provider of the same specialty in the same group practice.
Critical care: only one physician of same specialty in group may report 99291 on the same date; others report 99292.
Anesthesia (Medicaid and Marketplace): one provider may report 01967 and another in same group may report 01968.

Abbreviations and definitions

CMS definition and policy context

CMSCMS = Center for Medicare and Medicaid

Policy monitoringMolina Healthcare will monitor compliance with this policy and take corrective action as necessary to ensure adherence to coding and billing standards

Regulatory compliancePolicy ensures Molina operates in compliance with applicable laws and regulations and maintains billing and coding integrity

CPT definition and relevance

CPTCPT = Current Procedural Terminology

CPT add-on symbol acknowledgementCMS acknowledges the '+' symbol within the CPT Manual as indicative of add-on codes

Use in policyCPT terminology and symbols are used as references for identifying add-on codes in Molina's reimbursement guidance