General Surgery Coding Alert

Turn to NCCI for guidance if you-re in doubt about a bundle

The true meaning of a -separate procedure,- as designated by CPT, is somewhat counterintuitive, which can cause a great deal of confusion for coders and physicians alike.

Avoid this mistake: Don't assume that a -separate procedure- designation means you can always report the code separately if the physician provides the service. In fact, a separate procedure designation means that the procedure is bundled -- and therefore not separately reportable -- anytime the physician provides a more extensive, related service.

The Right Time to Unbundle

CPT designates -separate procedures- as those procedures that the physician normally performs as an integral part of another, more extensive procedure. Therefore, the only time you should report a separate procedure -separately- is when your surgeon provides it independent of any related procedure(s), says Joyce L. Jones, CPC, CPC-H, CCS-P, CNT, director of business operations for AMSURG in Nashville, Tenn.

-You need to pay attention to the description of the CPT code for separate procedures- Jones says.

Example 1: The physician performs laparoscopic jejunostomy (44186, Laparoscopy, surgical; jejunostomy [e.g., for decompression or feeding]) along with laparoscopic lysing of adhesions (44180, Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]).

In this case, you cannot report 44180 separately. The separate procedure designation for this code means that it is bundled to the related, more extensive procedure (44186).

Example 2: The surgeon performs small bowel resection (44120, Enterectomy, resection of small intestine; single resection and anastomosis) and places a gastrostomy tube (43830, Gastrostomy, open; without construction of gastric tube [e.g., Stamm procedure] [separate procedure]) at the same session.

CPT specifically defines gastrostomy as a -separate procedure,- and according to CPT conventions, a separate procedure is bundled to any major procedure that occurs in the same area (or, for instance, that takes place via a common incision).

But in this case, the gastrostomy tube placement occurs in a different anatomic location than (and is consequently unrelated to) the bowel resection. Therefore, payers should recognize the procedure as separate and reimburse separately, also.

In this case, you should report both 44120 and 43830, although you may have to append modifier 59 (Distinct procedural service) to 43830 to alert the payer that the gastrostomy tube placement occurred in a different anatomical area than the bowel resection.

-You should use the 59 modifier to indicate that the -separate procedure- is not a component of a more extensive procedure,- Jones says.

Rely on NCCI for Guidance

Rather than having to -guess- if a designated separate procedure is related (and therefore bundled) to another service that the physician provides on the same day, you can rely instead on the bundling edits listed in the National Correct Coding Initiative, Jones says.

Bottom line: The NCCI edits will tell you without a doubt if a -separate procedure- is included in another, more extensive procedure you wish to report.

Example: During colotomy (44025, Colotomy, for exploration, biopsy[s], or foreign body removal), the surgeon also performs continent ileostomy (44316, Continent ileostomy [Kock procedure] [separate procedure]). In this case, 44316 is a -separate procedure,- but is it truly separate of 44025?

Solution: A quick look at the NCCI edits reveals that 44316 is, indeed, bundled to 44025. In this case, therefore, you would not report 44316 separately because the ileostomy is an integral component of the more extensive colotomy.