Orthopedic Coding Alert

Medicare has clear guidelines for separate procedure.

Having clear documentation of the procedures your surgeon is doing and why one procedure is being listed as a separate procedure in your claim will make all the difference in your claims success. Josie Dunn, CPC, Department of Orthopaedics, University of Maryland Faculty Practices, Maryland shares what Medicare has to say about separate surgical procedures. "The CPT® surgery guidelines further state that 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."

Below is what 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, shares from Medicare:

"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."

A CPT® code with the 'separate procedure' designation may be reported 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. Modifier 59 (Distinct procedural service...) or a more specific modifier (e.g., anatomic modifier) may be appended to the "separate procedure" CPT® code to indicate that it qualifies as a separately reportable service," Stout adds.