February 22nd, 2019
Many procedures in the CPT® code book are designated "separate procedures," but that doesn't mean you can report those procedures separately in every case. First, you must consider other procedures performed during the same encounter.
"Separate" Might Not Mean What You Think It Does
You can always identify a designated separate procedure by the inclusion of "(separate procedure)" at the end of a code's descriptor (e.g., 29830 Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure)). A separate procedure designation identifies a procedure that may be performed independently or as part of a more extensive procedure, depending on the circumstances.
CPT® Surgery Guidelines tell us:
Some of the procedures or services listed in the CPT code book 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.
In other words:
- If a separate procedure is performed during a more extensive procedure in which it typically is included, it is not separately reported.
- If a separate procedure is performed alone, or with another procedure of which it typically is not a part, it may be separately reported.
For example, 29830 may be reported by itself to describe a diagnostic scope of the elbow, but is not separately reported (or reimbursed) with another arthroscopic procedure in the same elbow (e.g., 29834 Arthroscopy, elbow, surgical; with removal of loose body or foreign body).
NCCI Is Your Best Guide to Bundles
CPT® doesn't provide a complete list of codes to which a "separate procedure" may be bundled. Unless you have a full clinical understanding of the procedure performed, how can you know for certain whether a separate procedure is truly separate?
The answer is to consult the National Correct Coding Initiative (NCCI) edits (assuming your payer follows these edits) to determine if a designated separate procedure you wish to report triggers any NCCI edits. Encoder products such as AAPC Coder often include NCCI lookup tools, and your billing software may review claims for NCCI code pair edits automatically. The Centers for Medicare & Medicaid Services (CMS) updates NCCI edits each quarter (Jan. 1, April 1, etc.): Always use the most up-to-date version of NCCI when checking for edits.
An Edit Isn't Always the End of the Line
NCCI edits aren't absolute. Even if a designated separate procedure triggers an NCCI edit, you may still be able to report the service separately, if:
The NCCI code pair edit includes a "1" modifier indicator. Each NCCI code pair edit includes a modifier indicator. Codes with a "0" modifier indicator may never be reported separately. Codes assigned a "1" modifier indicator may be reported and reimbursed separately from the column 1 code, if the second condition also is met.
The separate procedure must truly be separate, and that condition must be identified by appending modifier 59 Distinct procedural service to the designated separate procedure code. As outlined in the CPT® surgery guidelines:
... when a procedure or service that is designated as a "separate procedure" is ... considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported ... 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).
For instance, if you check NCCI, you'll notice that 29830 is bundled to 29834, which is the more extensive service; but a modifier allows (the code pair edit includes a "1" modifier indicator) you to override the edit and report the diagnostic scope separately under the circumstances described above. For example, if the diagnostic scope and the surgical scope were performed in separate elbows, 29830 may be billed separately with modifier 59 appended because it represents a separate anatomical location. You also could apply the appropriate LT Left side and RT Right side modifiers to both 29830 and 29834 to designate which procedure occurred on which elbow.
This Week's Audit Tip Written By:
John Verhovshek, MA, CPC
Managing Editor, AAPC