Orthopedic Coding Alert

CCI is an important tool when you are not sure about a bundle.

You shouldn’t assume a “separate procedure” is really separate, because CPT^®’s definition of a separate procedure may not be what you think.

CPT^® uses a “separate procedure” designation in code descriptors to identify procedures that the physician normally performs as an integral part of a total service or procedure, but which she may, on occasion, provide independently.

Look out: Don’t assume that a separate procedure designation means you can always report the code separately if your orthopedist provides the service. In fact, a separate procedure designation means that the procedure or service is bundled -- and therefore not separately reportable — anytime the physician providesa more extensive, related procedure or service because CPT^® considers the separate procedure an integral component.

Think of it like a Happy Meal. You can either be billed for a hamburger alone (the separate procedure) or be billed for a combination that bundles a hamburger with fries and a drink (the more extensive related service), says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, with Coder on Call, Inc., in Milltown, New Jersey.

When your orthopedist carries out a procedure or service that CPT^® designates as a “separate procedure” unrelated to or distinct from other procedures or services provided at that time, you may report it in addition to the other procedures or services. Unless your specific carrier tells you otherwise, you would append modifier 59 (Distinct procedural service) to indicate that the separate procedure is not a component of another procedure or service, she adds. Modifier usage can be carrier-specific, so it is a good idea to track how your individual carriers prefer that you bill, experts say.

Look for Independent Procedure

Therefore, you should report a separate procedure only when your orthopedist provides the service independent of any related procedures.

Example 1: Your orthopedic surgeon performs an arthroscopic lateral meniscectomy (29881, Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]…), along with arthroscopic lysis of adhesions (29884, Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation [separate procedure]) in the same compartment.

In this case, you cannot report 29884 separately. The separate procedure designation for this code means that it is bundled to the related, more extensive procedure (29881).

Bonus tip: Don’t forget about specific anatomical site. For example, a physician performs bilateral diagnostic arthroscopies (29870, Arthroscopy, knee, diagnostic, with or without synovial biopsy [separate procedure]). On the left knee, however, she also performs a medial meniscectomy (29881).

You would report only 29881 for the left knee because the diagnostic arthroscopy would be bundled into it. But you would still be able to report the diagnostic scope on the right knee because nothing more extensive was performed on that side of the body. You could use either modifier 59 or modifiers RT (Right side) and LT (Left side) to show that these procedures were performed on different knees.

Rely on CCI for Guidance

Rather than having to guess whether 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 Correct Coding Initiative (CCI).

Bottom line: Medicare NCCI guidelines state:

33. If the code descriptor of a HCPCS/CPT^® code includes the phrase, “separate procedure,” the procedure is subject to NCCI PTP edits based on this designation. CMS does not allow separate reporting of a procedure designated as a “separate procedure” when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach.

Example 2: During a partial hip replacement (27125, Hemiarthroplasty, hip, partial [e.g., femoral stem prosthesis, bipolar arthroplasty]), the surgeon also performs hip flexor tenotomy (27005, Tenotomy, hip flexor[s], open [separate procedure]). In this case, 27005 is a “separate procedure,” but is it truly separate from 27125?

Solution: A quick look at the CCI edits reveals that 27005 is, indeed, bundled into 27125. In this case, therefore, you would not report 27005 separately because the tenotomy is an integral component of the more extensive hemiarthroplasty.