We have submitted 76000-26 with 23615 on a professional claim to the insurance, and they have responded that 76000-26 should not be reported in addition to 23615. Here is their specific response:
“An incidental procedure is one that is performed at the same time as a more complex procedure and is clinically integral to the successful outcome of the primary procedure. Some of the procedures or services listed in the CPT codebook that are commonly carried out as in integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure.” The codes with this designation should be not reported in addition to the code for the total service or service of which it is considered an integral component. However, when a procedure or service that is designated as separate procedure is carried out independently or considered to be unrelated or distinct from other procedures at that time, it may be reported by itself.”
We have read various resources that state CPT® codes designated as “separate procedures” are considered to be incidental and bundled with any related major procedure during the same session, through the same incision, and/or at same anatomic site, and that a separate procedure may be reported only if 1) It is the only procedure performed, or 2. It is unrelated to or distinct from other procedures performed during the same operative session (e.g., separate incision or site, performed on the ipsilateral/contralateral side, etc.). These resources state to refer to NCCI edits so you don’t have to guess when a “separate procedure” bundles to a related surgical service. The confusion is that there is no NCCI edit for 76000 and 23615.
Did CMS miss including this as an NCCI edit or is 76000 allowed to be separately reported with 23615 even when done during the same session through the same incision?
“An incidental procedure is one that is performed at the same time as a more complex procedure and is clinically integral to the successful outcome of the primary procedure. Some of the procedures or services listed in the CPT codebook that are commonly carried out as in integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure.” The codes with this designation should be not reported in addition to the code for the total service or service of which it is considered an integral component. However, when a procedure or service that is designated as separate procedure is carried out independently or considered to be unrelated or distinct from other procedures at that time, it may be reported by itself.”
We have read various resources that state CPT® codes designated as “separate procedures” are considered to be incidental and bundled with any related major procedure during the same session, through the same incision, and/or at same anatomic site, and that a separate procedure may be reported only if 1) It is the only procedure performed, or 2. It is unrelated to or distinct from other procedures performed during the same operative session (e.g., separate incision or site, performed on the ipsilateral/contralateral side, etc.). These resources state to refer to NCCI edits so you don’t have to guess when a “separate procedure” bundles to a related surgical service. The confusion is that there is no NCCI edit for 76000 and 23615.
Did CMS miss including this as an NCCI edit or is 76000 allowed to be separately reported with 23615 even when done during the same session through the same incision?