Separate Procedures Don’t Always Mean Separate Payment

By Sarah Sebikari, MHA, CPC

CPT® codes designated as “separate procedures” are generally incidental and bundled into a comprehensive/major procedure when performed during the same session, through the same incision, and/or on same anatomic site. The Centers for Medicare & Medicaid Services (CMS) does not allow separate reporting of a procedure designated as a separate procedure “when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach.”

A separate procedure may be coded independently or with a major procedure/service, however, if it is unrelated to or distinct from the major procedure/service. Appending modifier 59 Distinct procedural service to the separate procedure notifies the payer that the separate procedure was performed as a distinct service and is unrelated to the major service and, therefore, is payable. According to CPT® 2010 guidelines, modifier 59 may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries).

Be aware that not all National Correct Coding Initiative (NCCI) code pairs may be unbundled using a modifier. Any code pair edit with a “0” modifier indicator may not be unbundled; in such cases, the lesser of the two procedures always is included in the more extensive procedure. Coders must recognize when a separate procedure is integral to the comprehensive procedure/service being billed because NCCI edit tables do not always incorporate the separate procedures.

Learn more: For additional information on the NCCI modifier indicator, modifier 59, and separate procedures, see “Rev up Reimbursement with Modifier 59,” June 2010 Coding Edge, pages 34-36.

Questions and Cases Reveal Code Choices

Ask yourself five simple questions before separately coding a separate procedure:

1. Is the separate procedure a component of another major procedure?

2. Is the separate procedure performed independently?

3. Is the separate procedure unrelated to the major procedure?

4. Is the separate procedure distinct?

5. Is the separate procedure performed on the ipsilateral or contralateral side, same organ, and same incision/orifice?

If the answer to any of the above is “yes,” the separate procedure may be separately billable. To illustrate appropriate use, here are three cases that require bundling:

Case 1

After general anesthesia, the right hemithorax was prepped and draped, a thoracoscope was inserted, resection of apical blebs was performed, and exploration of chest was performed. At this point, a chest tube was inserted, the trocar was removed, and the site was closed.

In this example, the appropriate code is 32655 Thoracoscopy, surgical; with excision-plication of bullae, including any pleural procedure. Code 32551 Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure) is not coded as it was done on the ipsilateral (same side) of the thorax as the surgical thoracoscope, and is a designated “separate procedure.” The chest tube is considered incidental and integral to the surgical thoracoscopy.

Case 2

An arthroscopic surgical debridement and synovial biopsy of the right shoulder were performed on a patient with shoulder impingement. It would not be appropriate to report code 29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) in addition to the surgical arthroscopy code 29823 Arthroscopy, shoulder, surgical: debridement, extensive because 29805 is designated as a “separate procedure.”

The surgical arthroscopic procedure was performed on the right shoulder through the same incision during the same session as the diagnostic arthroscopy and is not separately coded. The CPT® manual clearly states at the beginning of each subsection for arthroscopic and endoscopic procedures, surgical endoscopy/arthroscopy always includes a diagnostic endoscopy/arthroscopy.

Case 3

After mobilization of splenic flexure, partial colectomy with anastomosis is performed. To get to the colon, physician frees intenstinal adhesions laparoscopically prior to resecting the diseased portion of the colon. The following codes are appropriate:

44204 Laparoscopy, surgical; colectomy, partial, with anastomosis

+44213 Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure)

Although intestinal adhesions were freed, 44180 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure) is not coded because freeing of adhesions is considered standard medical procedure. It is also designated as a separate procedure; thus it cannot be separately coded.

In this same case, if the physician documents the time spent freeing adhesions, 44204 may be billed with modifier 22 Increased procedural services. Most carriers require the documentation/operative report to be submitted with the claim to substantiate using modifier 22. Documentation such as, “60 minutes of my time was spent lysing adhesions prior to resecting the diseased colon,” is acceptable. Additional reimbursement of 10-25 percent of the allowed amount may be warranted, depending on complexity and time spent. Check with particular payers on proper modifier 22 usage and reimbursement.

Separate Procedures Calling for Separate Payment

As always in coding, there are two sides to the story: Separate procedures may be billed with unrelated procedures or distinct procedures, or may be billed if performed independently. Below are some examples were a separate procedure may warrant separate payment:

Example 1

A 40-year-old patient with a rectal abscess undergoes an incision and drainage. During the same session, a recurrent inguinal hernia is reduced. Appropriate coding is:

46040 Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure)

49520 Repair recurrent inguinal hernia, any age; reducible

Removal of the rectal abscess is unrelated to the hernia repair, so both procedures are reported.

Example 2

Patient with plica syndrome undergoes a limited synovectomy. If the synovectomy is the only procedure performed, report 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure).

Example 3

This following example is derived from the American Medical Association (AMA) CPT® Assistant, September 2000:

A patient with a claw foot and big toe bunion undergoes surgical correction of bunion. The phalanx is resected and plantar plate stabilized with a Keller wire. During the same session, the physician partially excises the bone of the fifth metatarsal head with the use of an osteotome. Thorough irrigation and sutures are applied.

Code 28292 Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride, or Mayo type procedure describes correction of a bunion of the metatarsophalangeal (MTP) joint (big toe). Code 28110 Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) describes partial excision of the metatarsal head bone.

In this example, code 28110 is considered a distinct and separate procedure from code 28292, so it is appropriate to report both codes to completely describe the procedures performed. Append modifier 59 to code 28110 when reporting these procedures to indicate a distinct procedure was performed.

If not appropriately coded, separate procedures may cause delay in payment. If a claim is denied, review documents to verify designated separate procedures were independent, distinct, or unrelated to the major procedure. Upon reviewing documentation and determining appropriate coding, these procedures may be warranted for payment with a multiple procedure reduction applied.

Sarah W. Sebikari, MHA, CPC, is senior coding analyst with Premier Health Care Exchange, a health care cost management company. She has been in the health care field for the past nine years, and is a certified coder for the past seven years, with experience spanning from multiple-specialty physician to outpatient coding and reimbursement.

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