The AMA Current Procedural Terminology (CPT) lists a term ‘Separate Procedure’ under surgery guidelines. The term refers to the procedures and services performed as integral components of a total service or procedure, as stated by the guidelines. It is very confusing to code the “separate” procedures or services that are carried out as a part of a major or comprehensive procedure during the same session, through the same incision and/or at the same anatomic site. Coding for such procedures is often error-prone as well. Here are the guidelines suggested by the American Academy of Professional Coders (AAPC) for coding separate procedures accurately.
- A separate procedure should be reported if it is the only procedure performed at a session or is starkly different from other procedures performed during the same session.
- Rather than guessing if a separate procedure is related to any service, check the National Correct Coding Initiative (NCCI) edits which list separate procedures with the related surgical service and specify which code pairs are reimbursed separately.
- Add modifier 59 (indicates distinct procedural service) to the separate procedure code when reporting a separate procedure. This will inform the payer that the separate procedure is carried out as a distinct service, not related to the major service and is therefore separately payable.
- Modifier 24 should be to indicate that a billed service is not part of a global (the global period is the time period prior to and/or after a surgical procedure) surgical package and is eligible for separate reimbursement. In other words, if the same physician provides an evaluation and management service during a postoperative period for a reason(s) unrelated to the original procedure, the physician can report the circumstance by adding modifier 24 to the appropriate level of E/M service.
AAPC gives two examples to understand the situations when separate procedure is reported. The first example tells about a shoulder impingement case in which an arthroscopic surgical debridement and synovial biopsy of the right shoulder are performed on the patient. Here, it is wrong to report 29805 (Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) as separate procedure code along with surgical arthroscopy code 29823 (Arthroscopy, shoulder, surgical: debridement, extensive), as both procedures are carried out on the right shoulder through the same incision and during the same session. Moreover, the CPT code book states that diagnostic endoscopy/arthroscopy is always included in surgical endoscopy/arthroscopy.
The second example is of a 55-year-old patient who undergoes an incision and drainage for rectal abscess abnormality. The surgeon also repairs recurrent inguinal hernia during the same session. As rectal abscess removal is entirely different from hernia repair, you need to report both procedures with appropriate codes (49520 (Repair recurrent inguinal hernia, any age; reducible) and 46040 (Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure). It is also required to add modifier 59 to the latter code.
Reporting bundled “separate” procedures is a common cause for claim denials and negative audit findings. Providers and coders are required to understand the coding scenario and ensure that no bundled procedures are billed separately. Thorough knowledge and proper care is imperative to code separate procedures accurately and avoid claiming illegitimate reimbursements. A professional medical billing and coding company that provides the service of AAPC certified coders who are highly proficient in handling CPT codes can help you tackle all kinds of difficulties related to coding separate procedures. With accurate and timely medical coding and billing from experienced medical coders and billers, providers will benefit from speedy and correct reimbursement.