The term “Separate Procedure” is part of the nomenclature found in the AMA Current Procedural Terminology® (CPT), in the “Surgery Guidelines” found in the front section of the book (page 45 in the 2007 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 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.
Important Disclaimer Notice (Updated 8/7/14)
CPT for ENT articles are a collaborative effort between the Academy’s team of CPT Advisors, members of the Physician Payment Policy (3P) workgroup, and health policy staff. Articles are developed to address common coding questions received by the health policy team, as well as to clarify coding changes and correct coding principles for frequently reported ENT procedures. These articles are not intended as legal, medical, or business advice and are not a guarantee of reimbursement. The information is also not meant to serve as the definitive or sole authority on billing and coding issues. The applicability of AAO-HNS billing and coding guidance for a particular procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. You should consult with your own advisors as well as Medicare or private carriers in making any decisions about how to bill and code particular services or procedures.