Defining ‘Separate Procedures’
According to CPT® surgery guidelines, some of the procedures or services listed in the CPT® codebook that are commonly carried out as an integral component of total service or procedure have been identified by the inclusion of the term ‘separate procedure.’ The CPT codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.
In simple language, if a ’separate procedure’ is performed alone, or with another procedure of which it typically is not a part, it may be separately reported. For example, CPT code 29870 may be reported by itself to describe a diagnostic scope of the knee, but is not separately reported or reimbursed with another arthroscopic procedure in the same knee (e.g., 29882 Arthroscopy, knee, diagnostic, with meniscus repair (medial OR lateral)). CPT doesn’t provide a complete list of codes to which a ’separate procedure’ may be bundled, so you should have a full clinical understanding of the procedure performed to know for certain whether a separate procedure is truly separate.
Deciding a Procedure as ‘Separate Procedure’
- For deciding procedure as ‘separate procedure’ first you must ask the question:
- Were there other procedures performed during the same encounter?
- Did I consult the NCCI edits?
- Did the other procedures coded at the same encounter ’include’ the base code?
- Consult the National Correct Coding Initiative (NCCI) edits to determine if a designated separate procedure triggers any NCCI edits. Centers for Medicare & Medicaid Services (CMS) updates NCCI edits at the start of each quarter. Always use the most up-to-date version of the NCCI when checking for edits. Also, check your commercial payers to determine if they follow these edits.
- Note that these NCCI edits aren’t absolute. Even if a designated separate procedure triggers an NCCI edit, you may still be able to report the service separately if:
- The NCCI code pair edit includes a ‘1’ modifier indicator, you may be able to code for it in addition to the primary procedure, based on the circumstances. Codes with a ‘0’ modifier indicator may never be reported separately. Codes assigned a ‘1’ modifier indicator may be reported and reimbursed separately from the column 1 code if the second condition is also met.
- The separate procedure may be truly separate, and that condition is identified by adding the -59-modifier distinct procedural service to the designated separate procedure code.
- Let’s understand the example of CPT code 29870 again. If you check the most recent version of the NCCI edits, you will see that 29870 is bundled into 29882, which is a more extensive service, but a modifier allows (the code pair edit includes a ‘1’ modifier indicator) you to override the edit and report the diagnostic scope separately, under the right circumstances. For example, if the diagnostic scope and the surgical scope procedure were performed in separate knees, 29870 may be billed separately with modifier -59 appended because it represents a separate anatomical location. You could also apply the appropriate LT left side and RT right side modifiers to both the 29870 and 29882 to designate which procedure occurred on the left or right knee.
Clinical Scenario 1: An accident victim undergoes debridement of a wound to the bone on the anterior lower right leg and debridement to the muscle on the posterior thigh of the same leg. Both wound sizes are less than 20 sq km. The debridement codes 11042 (debridement, muscle) and 11044 (debridement, bone) have a PTP edit because this code pair cannot be reported for debriding the same wound. However, the code pair has a CCMI of ‘1’ in recognition of the fact that the debridements may be performed at separate distinct anatomic sites. Because there is an NCCI edit, these procedures would be reported as 11044, 11042-59.
Clinical Scenario 2: A patient is unable to be liberated from a ventilator after an acute injury. A planned percutaneous tracheostomy (31600) and percutaneous endoscopic gastrostomy (43246) are performed in the same operative setting. Codes 31600 and 43246 do not have an NCCI edit, but the 31600 descriptor states ‘separate procedure,’ and the NCCI manual states to append modifier 59 to the separate procedure code. In this case, it would be acceptable to report 31600-59, 43246-51; however, it also may be unnecessary because it is clear that the two procedures are not in an anatomically related region or through the same skin incision. The use of modifier 59 will be based on payor preference.
Reporting bundled ‘separate procedures’ is a common cause for claim denials. Providers and coders are required to understand the coding scenario and ensure that no bundled procedures are billed separately. With accurate medical coding and billing from experienced medical coders and billers, providers will benefit from speedy and correct reimbursement. To know more about general surgery coding and billing services, please contact us at email@example.com/ 888-357-3226