A Quick Guide to “Separate Procedures”
CPT® codes designated as “separate procedures” are considered to be incidental and bundled with any related comprehensive/major procedure when performed during the same session, through the same incision, and/or at same anatomic site. A separate procedure may be reported only if:
1. It is the only procedure performed, or
2. It is unrelated to or distinct from other procedures performed during the same operative session (e.g., separate incision or site, performed on the ipsilateral/contralateral side, etc.).
Bonus tip: You never have to “guess” if a designated separate procedure is related (and bundled) to another service. Instead, just check the National Correct Coding Initiative (NCCI) edits. The NCCI will always bundle a “separate procedure” with any related surgical service.
When circumstances allow reporting of a designated separate procedure, you must append modifier 59 Distinct procedural service to the separate procedure code. This alerts the payer that the separate procedure was performed as a distinct service and is unrelated to the major service (and is separately payable).
For example, an arthroscopic surgical debridement and synovial biopsy of the right shoulder are performed on a patient with shoulder impingement. In this case, you may not report the “separate procedure” 29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) in addition to surgical arthroscopy 29823 Arthroscopy, shoulder, surgical: debridement, extensive because both procedures are performed on the right shoulder through the same incision, during the same session. Additionally, the CPT® codebook clearly specifies, “Surgical endoscopy/arthroscopy always includes a diagnostic endoscopy/arthroscopy.”
In a second example, a 55-yr-old patient with a rectal abscess undergoes an incision and drainage. During the same session, the surgeon reduces a recurrent inguinal hernia. Removal of rectal abscess is unrelated to the hernia repair; therefore, both procedures would be reported. The appropriate coding is 49520 Repair recurrent inguinal hernia, any age; reducible and 46040 Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure). You must also append modifier 59 to the latter code.