Internal Medicine Coding Alert
Comprehensive Versus Mutually Exclusive Codes
Florida Subscriber
Answer: Think of a comprehensive code as the parent in a family of codes. In a family of codes, there are two or more component codes that should not be reported separately because they are included in the comprehensive code as a member of the code family. Comprehensive codes include certain services that are separately identifiable by other component codes.
The component codes, as members of the comprehensive code family, represent parts of the procedure that may or may not be included in the code description and should not be listed separately when the complete procedure is done. However, the component codes are considered individually if performed independently of the complete procedure. For example, a simple repair (12001) and a biopsy (11100) are components of the comprehensive code for lesion removal (11400). If the lesion removal is the only procedure performed, the only code listed would be 11400. However, if the lesion is excised from the chest, and a second lesion on the back is biopsied, both 11400 and 11100 should be billed and modifier -59 (distinct procedural service) should be appended to 11100.
Mutually exclusive procedures differ from comprehensive and component procedures because one procedure is not considered to be part of, or bundled into, the other. These codes cant be billed at the same time, or as CCI states, codes which are mutually exclusive of one another [are] based either on the CPT definition or the medical impossibility or improbability that the procedures could be performed at the same session.
If two procedures/services considered mutually exclusive under the CCI policy are billed, the carrier will reimburse for the procedure with the lowest work relative value unit.
If, for example, multiple wounds are repaired in the same repair classification, coding is based on the sum of the length of the repairs. Therefore, 12001 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.5 cm or less) and 12002 (... 2.6 cm to 7.5 cm) cannot be billed together on the same date of service. Code only one from the repair classification (12001-12007) to indicate code 12001 as mutually exclusive of code 12002. For instance, if a patient presents with a wound of 2.0 cm and a second wound of 6.5 cm, you would not code both 12001 and 12002 but instead code 12004 (... 7.6 cm to 12.5 cm) to represent the total length of repair, which is 8.5 cm.
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