General Question for the Week of June 18, 2018

General Compliance Question of the Week

Question:

How does CMS define the term “separate procedure” that is used in CPT® code descriptions?

Answer:

In the National Correct Coding Initiative Manual for Medicare Services, section J, the Centers for Medicare & Medicaid Services (CMS) state the following.

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.

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.


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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.