Know When to Report a ‘Separate Procedure’
Question: Our surgeon placed an anal seton to treat a fistula, and they also performed an incision and drainage (I&D) of a perirectal abscess during the operation. We originally reported 46020 (Placement of seton) and 46040 (Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure)) for the surgeon’s work, but the claim was denied citing 46040 as a component of a more comprehensive procedure. I thought we were able to report the two codes together because 46040’s descriptor includes “separate procedure.” Can you clarify what “separate procedure” means? Pennsylvania Subscriber Answer: The term “separate procedure” in a code descriptor means that the procedure is usually considered a component of a more extensive procedure. In your case, the I&D of the perirectal abscess is a portion of the procedure reported with 46020. According to the CPT® guidelines, “The 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.” You may report the separate procedure code when the provider performs the procedure independently or if it is distinct from other operations performed at the same time. The separate procedure “may be reported by itself, or in addition to other procedures/services by appending modifier 59 [Distinct procedural service] to the specific ‘separate procedure’ code to indicate that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure,” per the CPT® guidelines. “Separate procedure” does not mean you should automatically bill it in addition to the main procedure — it actually means the opposite in most cases. The code is generally only reported when the procedure is performed independently from a more comprehensive related service. If the surgeon only performed the I&D, and no more comprehensive related anorectal procedure was done, then you can bill 46040 alone. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
