If you have been coding surgeries for awhile, you’ve likely seen the term “separate procedure” in some of the descriptions for the codes you use. Codes with the term “separate procedure” in their code descriptions are said to have a “separate procedure” designation in CPT (this is a phrase you may see in guidelines from the AMA and CMS). Even though this term has been used in CPT for many years, it is still a source of a lot of questions for coders and many inquiries I see on coding forums. Some people look at the term “separate” and think that a separate procedure is something that should always be reported separately (or in addition to) other codes on the claim. What the term “separate” in this phrase really means, though, is quite the opposite.
A “separate procedure” according to CPT guidelines is a procedure that is usually a routine part of completing a more comprehensive procedure. CPT states that you should not code a CPT with the terminology “separate procedure” in its code description when you are reporting a more extensive procedure that separate procedure is a part of. However, you can report a code with a “separate procedure” designation in its code description if it is 1) the only procedure performed and billed during that surgery or 2) is performed with other procedures that it is not a routine part of.
The NCCI Policy Manual, which is published by the Centers for Medicare and Medicaid Services (CMS), also contains guidelines regarding codes with a “separate procedure” designation in their description. In Chapter 1 of this manual in section J, the guidelines say that “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.” The guidelines make it clear that you should not report a code with the terminology “separate procedure” in the code description when it is performed with a “related procedure.” They further define related procedures as those occurring through the same incision, orifice (e.g., nasal, oral, etc.), or surgical approach (e.g., through the same endoscope).
The guidelines in this same chapter and section also clarify when it would be appropriate to report a CPT code with a “separate procedure” designation along with another CPT code: “A CPT code with a 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.” Before reporting a code with a “separate procedure” designation with another CPT code during the same surgery, look to see if the two procedures happen in anatomically unrelated areas and are completed through separate incisions or approaches.
To give an example, CPT 44005 is coded for lysis of adhesions. This is a surgical procedure where the surgeon creates an incision in the abdomen and breaks apart adhesions that have formed in the abdomen due to an infection or a prior surgery. CPT 44005 has a “separate procedure” designation in its description: Enterolysis, freeing of intestinal adhesions (separate procedure). Since CPT 44005 has the “separate procedure” designation, it would be appropriate to report this code in a couple of circumstances:
1) If lysis of adhesions was the only surgical procedure performed on that patient during that surgery, you can report CPT 44005 by itself. In this scenario, the lysis of adhesions was the planned procedure and the only procedure performed.
2) If lysis of adhesions is performed at one time during the day (e.g., 9:00 a.m.) and later that same day another abdominal procedure (e.g., a colectomy) is performed, you can report the lysis of adhesions in addition to the other abdominal procedure since the two occurred at different encounters. Modifier 59 or XE (separate encounter) would be added to CPT 44005 to clarify that the two procedures happened during separate encounters.
3) If lysis of adhesions was performed along with another procedure somewhere else in the body during the same surgery (e.g., lysis of adhesions in the abdomen and removal of a cyst from the arm), you could report both codes. In this scenario, the lysis of adhesions is not a routine part of removing the cyst in the arm but is totally unrelated to that second procedure and performed in an “anatomically unrelated area” through a “separate incision.” Therefore, you can justify reporting CPT 44005 with another code even though it has a “separate procedure” designation.
The scenarios above clarify when you can report lysis of adhesions (a CPT code with a “separate procedure” designation). However, there are also many surgeries where you cannot report lysis of adhesions separately. Lysis of adhesions performed during any other abdominal procedure (e.g., a gastrectomy, colectomy, appendectomy, cholecystectomy, etc.) cannot be billed separately. The reason the lysis of adhesions bundles during any other abdominal procedure is because, to gain access to the abdominal organs such as the stomach, colon, appendix, gallbladder, etc., it is necessary to first break up the adhesions. Therefore, the lysis of adhesions in this scenario is a routine part of completing the more comprehensive procedure and would be bundled.
What “separate procedure” scenarios have you encountered? A key part of coding is networking with other coders and learning together. Please share your experiences and questions in the comments field below.
