Orthopedic Coding Alert

CCI is an important tool when you-re not sure about a bundle

Warning: Don't assume a -separate procedure- is really separate. 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.

Don't make this mistake: 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 provides a more extensive, related procedure or service because CPT considers the separate procedure an integral component.

-Think of it like a Happy Meal,- says Betty A. Johnson, CPC, CCS-P, CIC, CCP, president and principal consultant of CPC Solutions Inc. -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).-

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, says Susan Vogelberger, CPC, CPC-H, CMBS, CCP, owner and president of Healthcare Consulting and Coding Education LLC in Poland, Ohio. 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.-

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, ... 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,- Johnson says. 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, Johnson says. -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: The CCI edits will tell you without a doubt whether a -separate procedure- is included in another, more extensive procedure you wish to report.

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.

Know the Rules Before You Jump at 59

Although you shouldn't be afraid to use modifier 59 when the medical necessity and documentation support it, you should never report 59 carelessly or merely to get claims paid.

You may use modifier 59 to identify procedures that are distinctly separate from any other procedure your orthopedist provides on the same date.

According to CPT instructions and Chapter 1 of the national Correct Coding Initiative, you may append modifier 59 when the physician:

• treats a patient during a different session
• treats a different site or organ system
• makes a separate incision/excision
• treats a different lesion
• treats a separate injury.