What does “Separate Procedure “mean in a CPT Code Description?

Question:

What does “separate procedure” mean when it follows a CPT code description?

Answer:

Per 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 inclusion of 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, report the code in addition to other procedures/services by appending modifier 59 to the specific “separate procedure” code. This indicates 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).

What does this mean in practice? If a code description includes the term “separate procedure”, if that procedure is in the same anatomic area as a more comprehensive procedure (for example, lyse of adhesions followed by a colectomy) only the more comprehensive procedure, the colectomy, is reported.

*This response is based on the best information available as of 02/16/23.

Secondary Payor Doesn’t Recognize Consultations

Question:

We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?

Answer:

We suggest calling CIGNA and ask how they want this handled according to their policies. WithMedicareyou have two options: (1) bill the appropriate category and level of service documented (e.g., for outpatient consults [99202-99215] or inpatient consults [99221-99223]) or (2) bill the consultation code, which will result in a denial of payment from Medicare and appeal on paper explaining the situation.

*This response is based on the best information available as of 01/19/23.

Consultation Coding in 2023

Question:

In 2023, will the level of service be determined by history, exam and medical decision making, or will this change?  I have heard it is changing.

Answer:

Beginning January 1, 2023, consultation codes 99242-99255) for both inpatient and outpatient services will be based on medical decision making or time.  However, keep in mind a clinically relevant history and clinical examination should also be documented.  Also, consultation codes 99241 and 99251 have been deleted.

*This response is based on the best information available as of 12/15/22.

Denial for 99214

Question:

I work with Dermatologists. I have taken a couple of your online webinars. I have a question regarding a denial of office visit 99214, I hope you can answer. The denial indicates that medical records do not support the level of service. In that type of situation, can we rebill the claim as a corrected claim to a 99213?

Answer:

I would not just change the coding to 99213 without reviewing the documentation first. In 2021 the guidelines for office or other outpatient E/M services changed in that either time or medical decision making determines the level. Of course a clinically relevant history and examination should be documented. I would review the note for the date of service denied and code the encounter based on the documentation and not just assume 99213 is the correct code to report. If you need E/M training for Dermatology KZA can help provide education to you and your dermatology practice on coding and documenting E/M services.

*This response is based on the best information available as of 11/17/22.

Reporting an Excision and Repair on the Same Day

Question:

My provider excised an epidermal cyst on the patient’s neck with a defect of 1.2cm. She also reported that she did an intermediate layered closure of the same size. I reported codes 11422 for the excision and 12041 for the suture repair. A modifier 59 was appended to code 12041 but the payer is denying it stating the modifier is inappropriate. I resubmitted the claim removing modifier 59 to the procedure 11422 but it denied for the same reason. Should I be using modifier 51 instead of 59?

Answer:

The excision 11422 and intermediate repair 12041 are not bundled under the National Correct Coding Initiative (NCCI).  You should not report these two services with Modifier 59.  You should report the repair with Modifier 51.

*This response is based on the best information available as of 10/20/22.

Billing Multiple Units

Question:

When billing 4 units of 11620 (4 charges with 1unit a piece with 76 modifier) to a Medicare Advantage plans we are getting denied for MUE stating that 3 units can only be reimbursed on the same date. Will changing the modifier to 59 bypass this edit or is it Medicare’s policy limit.

Answer:

An MUE of 3 is the maximum number of units you can report for a single beneficiary on a single date of service for the procedure. It would be inappropriate to bill the service with 4 units with Modifier 59.

*This response is based on the best information available as of 09/22/22.