Wiki NCCI Separate Procedure Guidelines

[BABS37]

I have a question regarding CMS's separte rule definition. It states:

J. CPT “Separate Procedure” Definition
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 throughthe 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 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.

So if a physician does a laryngoscopy and bronchoscopy- 31526 & 31622 at the same time with the same scope- then I probably can't bill out for both with a 59- I'd probably want to bill for the bronchoscopy- right? Thoughts?

 

[bonzaibex]

There are no CCI edits preventing you from billing both codes together. I ran them through my CCI edits checker, and I got a green light on both, which means you don't even need a 59 modifier.

That's all I've got. i couldn't find any CPT Assistant articles that deal with the billing of both procedures at the same time. Anybody else have some insight?

Becky, CPC

 

[BABS37]

Sorry- should have made myself clearer- 31526 & 31622 are not CCI edits that you will find on a list, they are CCI edits listed by insurance payor and are considered bundled when performed together. SO, you would need a 59 modifier. I was simply asking if these two procedures are being performed with the same scope, are they both technically a separate procedure to justify a 59 modifier???

 

[kvangoor]

Since 31622 is designated as a "seperate procedure" the 59 would only be appropriate if the 31526 was obviously NOT related. Seeing as they used the same scope and were some of the same areas I would think that you would not want to use the 59. I agree with just billing the bronch.

 

[prayercoder]

Same scope

Since both procedures were done with the same scope, I agree with you. You should only bill for the bronchoscopy-the most comprehensive code. The separate procedure designation would not apply in this situation; the bronch is not being done as part of a larger procedure.

(I'm sure this all depends on the insurance carrier).

The Medicaid NCCI Policy manual states, "If medically reasonable and necessary endoscopic procedures are performed on two regions of the respiratory system with different types of endoscopes,both procedures may be separately reportable. For example, if a patient requires diagnostic bronchoscopy for a lung mass with a fiberoptic bronchoscope and a separate laryngoscopy for a laryngeal mass with a fiberoptic laryngoscope at the same patient encounter, HCPCS/CPT codes for both procedures may be reported separately. It must be medically reasonable and necessary to utilize two separate endoscopes to report both codes.

Hope this helps.

 

[BABS37]

Thank you prayercoder! That's what I was thinking too. I agree with the second part of your response as well. I wish my physicians were looking for two different causes as to why they are performing both but they aren't. I didn't want to argue with them so I went ahead and sent in a couple of examples to be audited so I can back up the reason for not billing both. Guess we shall see how that goes Thanks for the feedback!!!