Carefully Reporting ‘Separate Procedures’ in Otolaryngology Billing

Otolaryngology, also known as ENT (Ear, Nose, and Throat) medicine, is a specialized field that deals with the diagnosis and treatment of head and neck disorders. Effective billing practices are essential in this field to ensure accurate reimbursement and compliance with regulations. In otolaryngology billing, understanding the concept and carefully reporting ‘separate procedures’ is crucial.

Defining “Separate Procedures” in Otolaryngology Billing

The term “Separate Procedure” is derived from the AMA Current Procedural Terminology® (CPT) and is explained in the “Surgery Guidelines” section of the CPT codebook. These guidelines state that certain procedures and services listed in the CPT codebook are considered “separate procedures.” This designation means that these procedures are commonly performed as integral components of a total service or procedure.

It is important to note that when a procedure is designated as a “separate procedure” in the CPT codebook, it should not be reported in addition to the code for the total procedure or service. In other words, if a primary procedure already includes the “separate” procedure or if the “separate procedure” significantly contributes to the time and complexity of the overall procedure, it should not be reported separately.

Medicare’s Role in Addressing Integral Parts and Total Procedures/Services

Medicare has its own set of guidelines known as the National Correct Coding Initiative (NCCI). The NCCI identifies CPT codes that represent either components of other procedures or procedures that cannot be performed on the same date of service by the same physician for the same patient. These codes are not payable when billed together.

It is important to note that Medicare does not always include the CPT “separate procedure” codes in the NCCI edits. Instead, Medicare assumes that coders will identify situations where a procedure is an integral part of the overall progression and should not be billed separately. However, there are cases where Medicare does include a CPT “separate procedure” code in the NCCI as a code that can never be unbundled, regardless of the circumstances.

Utilizing Modifier -59 for Distinct and Independent Procedures

Both Medicare and the CPT recognize that there are instances when a “separate procedure” or an NCCI-bundled code may be performed independently or considered distinct from other procedures/services provided on the same date. In such cases, physicians can use modifier -59 to indicate that the procedure is not a component of another procedure but is a distinct and independent procedure.

To conclude, while coding for otolaryngology procedures and services, it is crucial to consider the Medicare NCCI edits, the designated “separate procedure” codes in the CPT, and procedures that are commonly viewed as integral parts of more extensive procedures. Taking a comprehensive approach ensures accurate billing, reduces the risk of claim denials or audits, and promotes proper reimbursement for the services provided. Carefully reporting ‘separate procedures’ will safeguard reimbursement and contribute to the integrity and sustainability of otolaryngology practices.

About Medical Billers and Coders (MBC)

Medical Billers and Coders (MBC) is a leading otolaryngology billing company specializing in providing comprehensive billing services tailored specifically for ENT practices. With our in-depth knowledge and expertise in otolaryngology billing, MBC ensures accurate and compliant coding, timely submission of claims, and efficient revenue cycle management.

MBC’s commitment to staying updated with the latest coding guidelines and regulations ensures that ENT practices can focus on providing exceptional patient care while leaving complex billing processes in capable hands. For further information about our otolaryngology billing services, please reach out via email at or by calling 888-357-3226.