This commentary is a summary prepared by McKesson’s Revenue Management Solutions division and highlights certain changes, not all changes, in 2013 CPT® codes relating to the specialty of anesthesiology and pain management. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2013 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.

CPT is a registered trademark of the American Medical Association (“AMA”). The AMA is the owner of all copyright, trademark and other rights to CPT® and its updates.

“Separate Procedure” in CPT Coding

Many CPT codes include the term “separate procedure” in the description of the procedure or service. What does this mean? In order to determine if a code described as a separate procedure should be reported, you first must review the documentation to see why the provider is doing the separate procedure. Does the primary procedure encompass the separate procedure?

Let’s first take a look at the CPT definition for separate procedure along with the Centers for Medicare & Medicaid Services (CMS) description:

  • CPT states “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 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 the 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).” This information can be found on page 58 of the 2013 AMA CPT book Professional Edition.
  • CMS definition: “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 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.” This is located in the NCCI Policy Manual, effective 1/1/2013, Chapter 1, page 29.

In conclusion, it is always important to understand the CPT-designated separate procedure codes since many of these are considered part of the primary procedure. In many cases Medicare, will not include these ‘separate procedure’ codes into the NCCI edits, therefore leaving this up to the coder to recognize these situations.

 

Courtney Reasoner, CHC, CPC
Compliance director – Anesthesiology & Pain Management
McKesson Revenue Management Solutions

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