Author: Kimberly Mansingh

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.

If you work for a surgeon specializing in colorectal procedures, chances are you have seen your fair share of ostomy takedown procedures. When you first start checking CPT for a code for a “takedown,” though, you may find yourself coming up empty. The reason for this is that surgeons use the term takedown in their operative reports while CPT uses the word “closure” in the codes that cover this procedure. Both terms really have the same meaning, but until you know about the difference in language you may see in reports verses what you will see in the CPT manual, the whole thing can be pretty confusing. So let’s breakdown the terminology and codes for an “ostomy takedown” and see how that looks in CPT so you can quickly choose the correct code.

CPT describes an “ostomy takedown procedure” as “closure of an enterostomy.” An enterostomy is a surgically-created connection between part of the intestine and another structure. We can confirm the definition of enterostomy by breaking the word down into its parts: entero- means “of or pertaining to the intestine” (this could refer to either the small or the large intestine) while -ostomy means “an artificial opening between two structures.” So when we put these word parts together we have “an artificial opening between a part of the intestine and another structure.” In the context of these codes, the artificial connection was made between one end of the intestine and the abdominal wall. Some common enterostomies you may see include an ileostomy (connection between part of the last segment of the small intestine and the abdominal wall) and a colostomy (connection between any part of the large intestine, aka as the colon, and the abdominal wall). The CPT codes for the takedown procedure start with the word “closure.” The reason we see the word “closure” is because the surgeon will ultimately close up that artificial opening (or ostomy site) on the abdominal wall in a takedown procedure. So surgeons refer to these procedures as a “takedown” clinically because they are taking the end of the colon or small intestine that was connected to the abdominal wall back down into the abdomen while CPT calls these “closure of an enterostomy” because the surgeon is ultimately closing up that artificial opening on the abdominal wall. Both terms again really refer to the same procedure, but hopefully this explanation will help you line up the language you see in operative reports and what you see in your CPT manual.

With those definitions in mind, here are the three code choices for closure of an enterostomy:

• CPT 44620: Closure of enterostomy, large or small intestine

• CPT 44625: Closure of enterostomy, large or small intestine; with resection and anastomosis (other than colorectal)

• CPT 44626: Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (e.g., closure of Hartmann type procedure)

Let’s start breaking down the difference in these codes. Starting with CPT 44620, this is your code for your “basic” takedown procedure. In this procedure, the surgeon disconnects the end of the small or large intestine from the abdominal wall and reconnects that end to the remaining intestine back inside the body. He then closes the former ostomy opening on the abdominal wall. No part of the intestine is removed in this procedure. Instead, the end that was attached to the abdominal wall is simply reconnected (aka anastomosed) to the remaining intestine without resecting part of the intestine.

For CPT 44625, the physician is still disconnecting the end of the small or large intestine from the abdominal wall, but before reconnecting the end of the intestine to the remaining intestine in the body, part of the intestine that was connected to the abdominal wall and/or part of the remaining intestine “stump” (the end of the intestine that was inside the body) will be resected and removed. After removing the appropriate amount of intestine, the two ends of the intestine will be anastomosed back together. For CPT 44625, the anastomosis performed is any anastomosis other than colorectal. So in this procedure, you may see various parts of the intestine reconnected such as ileum to ileum, ileum to remaining colon, colon to colon, etc. If two structures other than the colon and the rectum are reconnected after removing part of the intestine and closing the ostomy site on the abdominal wall, it’s a 44625.

Finally, for CPT 44626, this procedure includes very similar work to what is described by CPT 44625, but in this procedure, the two structures anastomosed are the colon and the rectum (aka a colorectal anastomosis). This procedure may also involve resection of part of the remaining colon and part of the remaining rectum before creating that colorectal anastomosis. You will notice in the parentheses in the code description that CPT states this procedure may be coded for closure of a “Hartmann’s type procedure.” In a typical Hartmann’s procedure, one end of the colon is brought out to the abdominal wall as a colostomy while the remaining rectal “stump” is stapled closed. So in reversing a Hartmann’s, the surgeon would typically resect part of the colon that was attached to the abdominal wall and maybe “clean up” the end of the rectal stump and then perform a colorectal anastomosis. That’s why closing the ostomy created during a Hartmann’s procedure would typically fall under CPT 44626. It is important to note, though, that most but not all Hartmann procedure takedowns would be coded as 44626. In a modified Hartmann’s procedure, the surgeon will connect one end of the colon to the abdominal wall as a colostomy and then staple closed a “long Hartmann’s stump” that includes part of the sigmoid colon plus the rectum. If the surgeon closes the ostomy at a later date and the anastomosis created is between part of the colon that was connected to the abdominal wall as an ostomy and the sigmoid colon (rather than the rectum), you would code CPT 44625 (since the anastomosis would be colon to colon instead of colorectal). Small details here would make a difference in the coding.

Now that we have reviewed the codes, let’s look at a couple of examples to illustrate appropriate coding of these procedures.

Example #1: After sterile prep and drape, we made an incision through our previous midline laparotomy. Dense adhesions were encountered, but we were eventually able to gain access to the transverse colonic stump. We removed roughly 5 cm of colon to ensure no ischemic bowel remained. We then turned our attention to the abdominal wall where we circumferentially dissected around the ileostomy site. The end of the ileum appeared dusky so we removed 10 cm of ileum and then brought the remaining intestine down into the abdomen. The remaining ileum and transverse colon were aligned and using an EEA stapler, the anastomosis was complete. The ends of the bowel came together nicely in a tension-free anastomosis. We checked to ensure we had an airtight anastomosis and applied some Arista powder to ensure hemostasis. We then closed our opening on the abdominal wall and closed our midline incision. The patient tolerated the procedure well.

Answer Example #1: The bolded portions of the note above are keys to selecting the correct CPT code. We first see the physician enter the abdomen (a laparotomy is an incision into the abdomen), and he finds the “transverse colonic stump” (or the part of the intestine that was stapled off in the body during the prior surgery where the ostomy was created). He “removes” 5 cm of transverse colon (which is our first intestinal resection). He then comes up to the abdominal wall and circumferentially dissects (or separates all the way around) the connect between the ileostomy (the end of the ileum) and the abdominal wall. He then performs a second intestine resection, removing 10 cm of the ileum. Then he brings the ileum back into the abdomen, lines up the ileum and the transverse colon, and using a stapler creates an anastomosis (a connection between the remaining ileum and the colon). After making sure his anastomosis is intact by testing for leaks and controlling any bleeding (which is all part of the main procedure), he closes the opening from the ostomy on the abdominal wall. So we have closure of an enterostomy (in this case an ileostomy), with resection of intestine, and an anastomosis other than colorectal (since the anastomosis is between the ileum and the transverse colon). Those details support CPT 44625.

Example #2: After sterile prep and drape, we made an incision through our previous midline laparotomy. Dense adhesions were encountered, and we spent 90 minutes lysing adhesions to gain access to the abdomen. Access was very difficult due to multiple prior abdominal surgeries. Eventually we located our rectal stump. We opened up the prior sutures at the rectal stump and then turned our attention to the abdominal wall. We then circumferentially freed the colostomy from the abdominal wall. We resected 15 cm of colon then brought the remaining intestine down into the abdomen, ensuring we had adequate length to reach the rectum. The remaining colon and rectum were aligned. We passed the anvil of our EEA stapler into the remaining colonic end and passed the stapler via the anus. With a single fire, the anastomosis was complete. We introduced water into the pelvis and air into the colon via a rigid proctoscope to ensure there were no bubbles and verify that our anastomosis was intact. With this complete, we then closed the prior colostomy site on the abdominal wall and closed our midline incision. The patient tolerated the procedure well.

Answer Example #2: The bolded portions of the note above are keys to our code selection. We first see the surgeon entering the abdomen. In this case, the entry into the abdomen is significantly more complex than normal (he tells us he spent 90 minutes lysing/breaking up adhesions to gain access to the rectal stump due to the multiple prior abdominal procedures). We want to keep this detail in mind once we find our CPT code because this is a good example of a case where modifier 22, significant, increased complexity, could apply. He then tells us he “located the rectal stump” and “opens the prior sutures” (so he is preparing the rectal stump for anastomosis). He doesn’t remove any of the remaining rectum, and that’s okay (he is not required to do so, but may choose to remove part of the rectum when circumstances warrant that). He then comes up to the abdominal wall and frees the colostomy from the abdominal wall all the way around. He then removes (aka resects) 15 cm of the colon (so that’s our intestinal resection). He makes sure he still has good length of colon to reach the rectum and brings the colon down into the abdomen where he lines it up with the rectal stump. The bolded portions here are key words that describe using tools such as staplers and anvils to bring the colon and the rectum back together (aka a colorectal anastomosis). He then checks for leaks (again no matter how they do that through water, air, a scope, etc. that is all part of the main procedure). The surgeon then closes the ostomy opening on the abdominal wall. So we have a takedown of a colostomy, resection of part of the colon, a colorectal anastomosis, and closure of the opening on the abdominal wall. These details support CPT 44626. Again, I would also add modifier 22 and diagnosis code K66.0 (postoperative adhesions of the intestine) due to the 90 extra minutes it took to gain access to the abdomen at the start of the case.

I hope the explanations and examples in this article help you code ostomy takedowns with confidence. If you have an example that wasn’t addressed in this article, please reach out in the comments section below.

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The topic of scout endoscopies is one that comes up often for coders in all different specialties because surgeons often perform these procedures during non-endoscopic procedures in the chest, abdomen, and pelvis to help them visualize the organs/structures they are working on or ensure successful completion of their procedure. Distinguishing a diagnostic endoscopy from a scout endoscopy can be difficult at first, but fortunately, we have some guidelines that can help us.

In the NCCI Policy Manual which is published each year by the Centers for Medicare & Medicaid Services (CMS) a “scout endoscopy” is defined a couple of different ways. The first definition we see for a “scout endoscopy” is a type of endoscopy that may be performed before a non-endoscopic surgery:

A “scout” endoscopy to assess anatomic landmarks or assess extent of disease preceding another surgical procedure at the same patient encounter is not separately reportable. – NCCI Policy Manual, Chapter 6, section C.6

An electromyogram (or EMG) is a test commonly performed by neurologists to test the health and electrical response of the muscles. During an EMG, small needle electrodes are passed through the skin and into the muscles being tested to measure the electrical activity of the muscles as patients are asked to contract and relax the muscle being tested. The physician uses special equipment to listen to and/or visualize the muscle activity. The goal of the EMG is to confirm if muscle activity is normal or if there are abnormalities which indicate a disease/disorder of the muscles. An EMG test can be useful in diagnosing disorders of the muscles or nerves that provide electrical signals to those muscles including conditions such as carpel tunnel syndrome, multiple sclerosis (MS), and muscular dystrophy.

An EMG is most commonly performed on muscles in the arms and legs (also known as the “limb muscles”), but may be performed on muscles of the head, neck, and trunk as well. Our article today will focus on how to code EMGs of the limb muscles since these procedures are so commonly performed. If you do have questions about coding EMGs of the head/neck/trunk muscles, head over to our “contact” page on our website to ask your question there or comment on this article, and I will be happy to assist with those additional questions.

The first thing to know about EMG testing of the limbs is that it may be performed by itself or in conjunction with another test known as a nerve conduction study (NCS) during the same encounter. Nerve conduction studies measure the speed at which nerves relay signals to the muscles they innervate (or communicate with). There are different codes for EMGs of the arms/legs when performed with an NCS when compared to EMGs performed by themselves without an NCS. We will look at our code options in detail in just a moment.

The next thing to know about EMGs of the limbs is that they may be either limited or complete.

• A limited EMG of the limb involves testing 4 or fewer muscles in a single limb.

• A complete EMG of the limb involves testing 5 or more muscles in a single limb.

One common mistake I see coders make when counting muscles to determine if the EMG is limited or complete is counting all muscles tested in multiple limbs together and then concluding the EMG is complete. So to clarify this concept of limited vs. complete, you need to determine how many muscles are tested in a “single limb” and decide if the EMG in that one limb is limited or complete. While more than one limb is often tested in a single encounter, you will count “one” for each named muscle tested in each limb to get your total muscle count for that limb — the muscles tested in each limb are counted separately “by limb” and not calculated all together for purposes of EMG coding. Example: If a physician performs an EMG on the right arm and right leg that is “two limbs” for purposes of EMG coding. You will need to determine if the EMG in the right arm is limited or complete and then decide separately if the EMG in the right leg is limited or complete. Using this example of an EMG on the right arm and right leg, if the right deltoid, right biceps brachii, right triceps brachii, and right abductor pollicis longus were tested (all of which are right arm muscles which gives us four muscles in total for the right arm) and then the right vastus lateralis, right biceps femoris, right tibialis anterior, right peroneus brevis, and right extensor digitorum longus muscles were tested (all of which are right leg muscles which gives us five muscles in total for the right leg), the right arm EMG would be limited (four or fewer muscles in that limb) while the right leg EMG would be complete (five or more muscles tested in that limb). As you can see, not all limbs have to undergo the same level of testing (some may be limited while others are complete). Whether a limited or complete EMG is performed in each limb depends on the patient’s symptoms and the condition the physician is trying to rule out or confirm.

Now that we have some ground rules laid out, let’s look at the codes for EMGs. We will first look at the codes for EMGs performed alone without a nerve conduction study during the same case/encounter:

• CPT 95870: Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles other than thoracic paraspinal, cranial-nerve innervated muscles, or sphincters

• CPT 95860: Needle electromyography; 1 extremity with or without related paraspinal areas

• CPT 95861: Needle electromyography; 2 extremities with or without related paraspinal areas

• CPT 95863: Needle electromyography; 3 extremities with or without related paraspinal areas

• CPT 95864: Needle electromyography; 4 extremities with or without related paraspinal areas

Much of the confusion regarding how to code EMGs starts with the wording of these particular CPT codes. As you can see, CPT 95870 may be used for a “limited electromyography (EMG) in 1 extremity” (so we at least see the words limited and extremity in this code description); however, CPT 95870 also may be used for a variety of other purposes (e.g., to report EMG testing of non-limb muscles other than the exclusions such as sphincter muscles listed in the CPT code description). The number of different reasons that one might report CPT 95870 often confuses coders and makes the “limited EMG 1 extremity” portion of the code description easy to overlook. Neveretheless, if your physician performs a limited EMG of a limb(s) and does not perform a nerve conduction study during that same encounter, CPT 95870 is your code. You will report one unit of 95870 for each limited EMG performed in a different extremity. Example: If a physician tests the right arm and left arm during an EMG with testing of the bilateral deltoid, bilateral biceps brachii, bilateral triceps brachii, and bilateral adductor pollicis longus muscles, you have four muscles tested in each limb which is two limited EMGs. You would code 95870 x1 for the right arm and then 95870.59 (or XS for separate site if the patient has Medicare) x1 for the left arm. Note: Payer guidelines may vary on whether they want you to code 95870 x2 on one line of code or 95870 x1 and 95870.59 x1 (or XS) on two lines of code. In my experience, reporting on separate lines of code is generally more accepted by payers, but be sure to check your payer guidelines to ensure appropriate coding.

CPT codes 95860-95864 are worded in a more straightforward manner than CPT 95870 (in that the descriptions contain the word electromyography which again means EMG and tells us how many extremities should be tested to report the code). However, nowhere in these code descriptions do we see the word “complete” which we discussed earlier. We have to go to the CPT guidelines which appear in the paragraphs leading up to these codes in the CPT manual to get our instructions about these codes being restricted to reporting complete EMGs only and about what is considered a limited and what is considered a complete EMG to even begin choosing between these codes. Here are the CPT guidelines that support what I shared earlier about how a limited and complete EMG are defined: “Use 95870 or 95885 when four or fewer muscles are tested in an extremity. Use 95860-95864 or 95886 when five or more muscles are tested in an extremity.” Therefore, even though the code descriptions of CPT 95860-95864 themselves don’t mention the word “complete,” because the CPT guidelines restrict the use of these codes to complete EMGs where five or more muscles are tested in an extremity, you may only report 95860-95864 if you are reporting complete EMGs in the number of extremities listed in the code description.

Another interesting part of the CPT code description for 95860-95864 is the phrase “with or without related paraspinal areas.” The paraspinal muscles run alongside the spine. Related paraspinal muscles refers to those paraspinal muscles that line the part of the spine with nerves that are branching off of the spinal cord and innervating the limb muscles being tested during the EMG (e.g., cervical paraspinal muscles would be included in EMG testing of the arm(s) as the “related paraspinal muscles” while lumbar paraspinal muscles would be included in EMG testing of the leg(s) as the “related paraspinal muscles”). The AMA has stated in CPT Assist December 2010 that the paraspinal muscles in these related paraspinal areas cannot be tested independently without testing the corresponding limb muscles which is why the testing of these muscles is included in codes 95860-95864 and not separately reported. The AMA also states in this same article that you may count the paraspinal muscles as one of your five muscles needed to code a complete EMG in the limb being tested.

Now that we have looked at the codes for the stand-alone EMG codes, let’s take a look at the codes for EMGs performed with nerve conduction studies during the same case/encounter:

• CPT 95885: Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)
• CPT 95886: Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete (List separately in addition to code for primary procedure)

These codes are more optimally worded. As you can see, CPT 95885 is reported for a limited EMG during a nerve conduction study while CPT 95886 is reported for a complete EMG during a nerve conduction study. These codes also include the phrase “each extremity” confirming that one unit of the code should be reported for each limb in which a limited or complete EMG is performed. Example: If the bilateral legs are tested with EMG during a nerve conduction test with testing of the vastus lateralis, biceps femoris, and tibialis anterior muscles on both legs, this case would be coded as CPT 95885 x2 for the two limited EMGs during a nerve conduction test since three muscles are tested in each leg (which is two limbs in total). As with codes 95870 and 95860-95864, it’s possible for one limb to be tested and support a complete EMG while the other limb is tested and only supports a limited EMG. It’s important to assign the code that most accurately reflects the level of testing “per limb.” Finally, we see the phrase “list separately in addition to code for primary procedure” which means these codes 95885-95886 are “add on codes” in CPT. They may only be reported when a nerve conduction study (CPT 95907-95913) has been reported. If a nerve conduction study was not performed, do not report these codes (instead go back to codes 95870 or 95860-95864 to report your EMG test).

I hope this information helps you the next time you code an EMG case. If you have specific questions about challenging EMG scenarios, feel free to drop us an email using the contact form on our website.