Wiki Separate Procedures

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dimplez

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Hello - Can a procedure that is defined as a 'separate procedures' be reported with another even if it is done through a separate incision if it done at the same anatomical site? Our surgeon was performing plantar fasciectomy with tarsal tunnel release (28062 or 28060 with 28050) under one incision; however, once this was brought this to his attention he began to do separate incisions and specifically emphasizes this within his operative notes. Any resources out there as to the appropriate reporting?

CPT Manual Surgery Guidelines
Separate Procedure (Surgery)
Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term "separate procedure." 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.
However, when a procedure or service that is designated as a "separate procedure" is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 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. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries).

If the code descriptor of a HCPCS/CPT code includes the phrase “separate procedure,” the procedure is subject to NCCI PTP edits based on this designation. 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

Source: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-3.pdf

Thanks!!
 
I think it depends. Does the patient have both tarsal tunnel syndrome and plantar fasciitis? What's the reason both are being done at the same time? If it's to treat the pain of plantar fasciitis by doing the combined procedure, even if there were two incisions, you would have to look at the intent of the treatment and diagnosis code(s). I think it would be iffy. It may need to be considered on a case by case basis depending on the patient and documentation. It's still the same anatomical area.

Note - tarsal tunnel release is 28035 not 28050 (typo?)
 
Hi - yes, absolute typo, apologies. So, if they each have a dx to support, both can be reported? Even if one incision or would it be necessary to do separate?
Thanks for the response!
 
dimplez said:
Hi - yes, absolute typo, apologies. So, if they each have a dx to support, both can be reported? Even if one incision or would it be necessary to do separate?
Thanks for the response!
Click to expand...
I think it would still be questionable. It is really going to depend on each case and the documentation. If there were two different dx and the documentation supported it, I *might* do it. The provider would have to decide if the procedure was "carried out independently or considered to be unrelated or distinct from other procedures/services".
 
Totally agree with Amy. Read the "Separate Procedure" guidelines in your CPT book. Just because it was performed through a separate incision doesn't mean that it automatically qualifies to be reported.
 
Same incision, separate incision...does not matter from a coding standpoint if they are procedures performed to treat different conditions. Don't get confused with bundling and separate procedures. There are many codes that have a combination of procedure codes bundled into one code. However, those designated as separate procedures can be coded alone. This "separate procedure" definition is telling you that there may be another code that this bundles into.
In the case of a fasciectomy and tarsal tunnel release, these are different procedures to treat different conditions and do not bundle together nor is the tarsal tunnel release considered an integral part of the fasciectomy nor vice versa. The tarsal tunnel is not related to the plantar fascia. The key is the documentation. It must separately identify the two conditions of plantar fasciitis and tarsal tunnel syndrome for which the procedures are being performed.
 
Isn't coding fun! :) It would be helpful to see a redacted report to see exactly what it says.
I agree with Tonia, it goes back to the documentation. We can't give a definitive answer to this question which would apply in all cases. They are two different and distinct conditions but the documentation would have to clearly indicate that. In reading, these two conditions are often mistaken for one another and/or occurr concurrently. If it's for both plantar fasciitis with/and tarsal tunnel syndrome you'd most likley report both codes. It's probably rare that you wouldn't be able to report both.

surgical release with plantar fasciotomy and distal tarsal tunnel decompression
  • indications
    • concomitant compression neuropathy (tibial nerve in tarsal tunnel)
However, I would point out the procedures *might* be done concurrently, to treat "heel pain" or "subcalcaneal pain syndrome" in some cases. They may not always separate and distinct, a combo-procedure *may* be done. If the documentation only said heel pain or pain syndrome or something and was not super clear.

The AAOS global service book is silent on these when you look up the three different codes. I agree they are not integral to one another. The payer being billed might not care and may deny the separate procedure anyway simply because it has that designation. Even though the codes in question don't hit edits, you might have to apend a 59 to get paid for the separate procedure code.

What's more concerning to me is if the provider truly changed the process by which he performs a case to make two incisions versus one to be able to call out separate incisions, but that's another story. Changing the actual surgical process to try and meet a coding guideline....?
 
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