Wiki What if both codes are Separate Procedure ?

[betsycpcp]

I can't find anywhere that specifically addresses this: what if the only 2 procedures done are both "separate procedure" according to CPT? The example I have is 28272 (capsulotomy interphalangeal joint) and 28232 (open tenotomy, flexor tendon, toe). Both have "(separate procedure)" in the description. If separate procedure means that procedure is only to be reported if it's separate or distinct from other procedures done at the same time, how is it determined which procedure to bill, or whether to bill both?

In this example, the capsulotomies and tenotomies were both done at the same time to the same toes, through the same incisions. NCCI lists 28232 as bundling with 28272, but AAOS doesn't list 28232 as being included with 28272. This is Ohio workers' comp which uses NCCI for outpatient hospital, but not necessarily for professional fees (which is what I have).

 

[VioletP]

In my opinion you can not bill both procedures. Per NCCI edits they are bundled and in order for them to be unbundled with modifier 59 the following must apply.

 Different session or patient encounter;
 Different site or organ system;
 Separate incision/excision;
 Separate compartment;
 Separate lesion; or
 Treatment of a separate injury (or area of injury in extensive injuries).

Because it is on the same toe different site does NOT apply and a separate incision was NOT made. I would bill the code with the hightest RVU in this case it would be the 28272