General Surgery Coding Alert

CPT® and Medicare rules agree.

When your surgeon uses a code that CPT^® identifies with the words "separate procedure," you better check your claim carefully to make sure you won’t face denials.

Look to CPT® for Definition

CPT^® surgery guidelines define separate-procedure codes as services "that are commonly carried out as an integral component of a total service or procedure…" The designation restricts when and how you can report separate-procedure codes with any other related procedures, according to the guidelines.

For example: Under most circumstances, you shouldn’t report 44180 (Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]) with other intestinal laparoscopy codes for the same patient on the same day.

Follow Medicare Guidelines, Too.

Medicare also gives clear instruction about when to use separate-procedure codes. According to Josie Dunn, CPC, at the University of Maryland Faculty Practices, Medicare states: "… the codes listed as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service. In other words, report a separate procedure if it is not performed with a primary procedure that encompasses the ‘separate’ one, or when it adds ‘appreciably to the time and/or complexity of the procedure.’"

Medicare also states, "If a CPT^® code descriptor includes the term ‘separate procedure,’ the CPT^® code may not be reported separately with a related procedure. CMS interprets this designation to prohibit the separate reporting of a ‘separate procedure’ when performed with another procedure in an anatomically related region, often through the same skin incision, orifice, or surgical approach."

Opportunity: You may report a CPT^® code with the "separate procedure" designation with another procedure if it is performed at a separate patient encounter on the same date of service or at the same patient encounter in an anatomically unrelated area (often through a separate skin incision, orifice, or surgical approach).

Do this: Append modifier 59 (Distinct procedural service) or a more specific modifier (e.g., anatomic modifier) to the "separate procedure" CPT^® code to indicate that it qualifies as a separately reportable service, says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and director of orthopedic coding division, The Coding Network, LLC, Beverly Hills, CA.