Many Current Procedural Terminology (CPT®) codes include the term 'separate procedure' in the description of the procedure or service. What does this mean? In order to determine if a code described as a 'separate procedure' should be reported, you must first review the documentation to see why the provider is doing the separate procedure. Does the primary procedure encompass the separate procedure?
First, take a look at the CPT description for separate procedure along with the Centers for Medicare & Medicaid Services (CMS) description.
- According to CPT, "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 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.
However, when a procedure or service that is designated as a 'separate procedure' is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported by itself, or in addition to other procedures/services."1 The modifier 59 must be appended "to the specific 'separate procedure' code to indicate that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries)."2
- According to CMS, "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."3
In conclusion, it is always important to remember the CPT designated 'separate procedure' codes since many of these are considered part of the primary procedure. In many cases, Medicare will not include these 'separate procedure' codes in the NCCI edits, which leaves it up to the coder to recognize these situations.