The term “Separate Procedure” is part of the nomenclature found in the AMA Current Procedural Terminology® (CPT) within the “Surgery Guidelines” that can be found in the front section of the book (page 72 in the 2023 Professional Edition). The guidelines state that some of the procedures and services listed in the CPT codebook that are commonly carried out as integral components of a total service or procedure have been identified by the term “separate procedure.”
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.”
Medicare addresses the concept of integral parts and total procedures/services through use of the National Correct Coding Initiative (NCCI). NCCI lists CPT codes that either: 1) represent components of other procedures and therefore, cannot be reported with that other procedure, or 2) represent procedures that cannot be performed on the same date of service, by the same physician, for the same patient, and therefore, are not payable when billed on the same date.
Both Medicare and CPT acknowledge that there are times when a “separate procedure” (CPT or an NCCI-bundled code) may be performed independently or may be considered to be unrelated or distinct from other procedures/services provided on the same date. In those instances, the physician can append modifier -59 to the “separate procedure” code. Modifier -59 indicates that the procedure is not a component of another procedure, but is a distinct, independent procedure.
A word of caution: Medicare does not always incorporate the CPT “separate procedure” codes into the NCCI edits, but rather, assumes that the coder will recognize coding scenarios in which a procedure or procedures are an integral part of the progression to the end procedure and, therefore, may not be billed separately. Conversely, Medicare may incorporate a CPT “separate procedure” code into the NCCI and list it as a code that can never be unbundled, regardless of the scenario.
Whenever you are coding for procedures and services, it is important to consider the Medicare NCCI edits, the CPT-designated “separate procedure” codes, and those procedures / services that are routinely viewed as an integral part of another, more extensive, procedure.
Revised October 2023