When coding for services and procedures, it’s critical for healthcare providers to pay attention to the “separate procedure” designation assigned to certain Current Procedural Terminology (CPT®) codes.
According to National Correct Coding Initiative (NCCI), the narrative for many HCPCS/CPT codes includes a parenthetical statement that the procedure represents a "separate procedure." The inclusion of this statement indicates that the procedure can be performed separately but should not be reported when a related service is performed. A “separate procedure” should not be reported when performed along with another procedure in an anatomically-related region through the same skin incision or 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. Modifiers 59 or XE or XS (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.
CPT surgical guidelines state, “Some of the procedures or services listed in the CPT® codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of term ‘separate procedure.’ The codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.”
NCCI’s General Correspondence Language and Section-Specific Examples provide helpful examples of this coding rule:
| "Separate Procedure" Code Designation | Rationale |
|
CPT code 19100 – Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) |
When an excision of a breast lesion (CPT code 19125) is performed, the procedure described by CPT code 19100 does not meet the definition of a “separate procedure” when performed on the same breast. Therefore, CPT code 19100 cannot be reported separately and is bundled into CPT code 19125 when both services are performed on the same breast. |
|
CPT code 29870 – Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) |
When a surgical arthroscopy of the knee with major synovectomy in two or more compartments (CPT code 29876) is performed, the procedure described by CPT code 29870 on the same knee does not meet the definition of a “separate procedure” Therefore, CPT code 29870 cannot be reported separately and is bundled into CPT code 29876 when both services are performed on the same knee. |
|
CPT code 33210 – Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) |
When a coronary artery bypass with single arterial graft procedure (CPT code 33533) is performed, the procedure described by CPT code 33210 does not meet the definition of a “separate procedure.” Therefore, CPT code 33210 cannot be reported separately and is bundled into CPT code 33533. |
|
CPT code 44005 – Enterolysis (freeing of intestinal adhesion) (separate procedure) |
When a partial colectomy with anastomosis (CPT code 44140) is performed, the procedure described by CPT code 44005 does not meet the definition of a “separate procedure.” Therefore, CPT code 44005 cannot be reported separately and is bundled into CPT code 44140. |
|
CPT code 49000 – Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) |
When a total abdominal hysterectomy, with or without removal of tubes and/or ovaries (CPT code 58150) is performed, the procedure described by CPT code 49000 does not meet the definition of a “separate procedure.” Therefore, CPT code 49000 cannot be reported separately and is bundled into CPT code 58150. |
Diligence and a comprehensive understanding of CPT and NCCI rules are at the core of correct coding. If you have questions regarding “separate procedure” designations, MMG is here to help. Contact us to set up a meeting with one of our experts.
Cindy Fasline, CPC, CH-CBS
References:
NATIONAL CORRECT CODING INITIATIVE’S (NCCI) GENERAL CORRESPONDENCE LANGUAGE AND SECTION-SPECIFIC EXAMPLES (FOR NCCI PROCEDURE TO PROCEDURE (PTP) EDITS AND MEDICALLY UNLIKELY EDITS (MUE)) https://www.cms.gov/medicare/coding/nationalcorrectcodinited/downloads/2017-ncci-correspondence-manual.pdf
CHAPTER I GENERAL CORRECT CODING POLICIES FOR MEDICARE NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-1.pdf
Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2016 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.