General Question for the Week of June 18, 2018

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.

CPT^® is a registered trademark of the American Medical Association.