Practice Management Alert

Medicare has clear guidelines for separate procedure.

Having clear documentation of the procedures your surgeon is doing and why one procedure is being listed as a separate procedure in your claim will make all the difference in your claims success. Medicare has a clear definition about what constitutes a separate surgical procedure. According to Josie Dunn, CPC, at the University of Maryland Faculty Practices, Maryland, Medicare states: "The CPT® surgery guidelines further state that the codes listed as 'separate procedure' should not be reported in addition to the code for the total procedure or service. In other words, report a separate procedure if it is not performed with a primary procedure that encompasses the 'separate' one, or when it adds 'appreciably to the time and/or complexity of the procedure.'

Below is what Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and director of orthopedic coding division, The Coding Network, LLC, Beverly Hills, CA, shares from Medicare:

"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 (Distinct procedural service...) 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, Stout adds.