Scope
This policy applies to all Commercial, Medicare Advantage, and Medicaid/EOCCO claims.


Reimbursement Guidelines
If a CPT code descriptor includes the term “separate procedure”, the CPT code may not be reported
separately with a related procedure. Moda Health follows CMS/NCCI Policy Manual guidelines to
determine whether or not the “separate procedure” code is related to the other procedure codes
billed.


Codes designated as “separate procedure” CPT codes are eligible for separate reimbursement when
they are the only procedure code reported for that joint, body part, or organ system during that
surgical session.


Many CCI procedure-to-procedure (PTP) edits deny “separate procedure” CPT codes as included in
related comprehensive codes. Some of these edits are eligible for a modifier bypass (modifier
indicator of “1”), and others are not (modifier indicator of “0”). Other code combinations do not
appear in the CCI PTP edits; the claims processing bundling edits are based upon the separate
procedure guidelines found in the CCI Policy Manual (CMS2 ) guidelines.


A CPT code with a descriptor including the term “separate procedure” may be reported with a
bypass modifier in combination with a more comprehensive related procedure code when the
modifier indicator is a “1” and the following criteria is met:

Modifier XE may be appended when the “separate procedure” service is performed first,
the patient leaves the operating room, is recovered, and hours later on the same date of
service needs to return to the operating room for a more comprehensive procedure on the
same organ system or a related body part.

Modifier XS may be appended when the “separate procedure” service is performed on one
side of the body (e.g. left knee) and the more comprehensive, related procedure code is
performed on the contralateral (opposite side) of the body (e.g. right knee).


Modifier XS may be appended to a separate procedure code when performed during the
same operative session as a more comprehensive related code, but the “separate
procedure” service is performed on one lesion and the more comprehensive, related
procedure code is performed on a different lesion which is not touching the first lesion
(non-contiguous). The two lesions may be located in the same organ (e.g. breast, liver, etc.)
or different organs (depending upon the code descriptions involved), or on the skin but not
touching or located in a different area.


Not Eligible for Bypass-Modifier Usage or Separate Reimbursement


A code designated as “separate procedure” may not be reported with a modifier for separate
reimbursement in combination with a more comprehensive, related procedure when:
 Both codes are performed on the same joint or body part during the same operative
session.
o The use of a separate surgical approach (laparoscopic versus open approach) or a
separate incision is not a sufficient reason to use a modifier to obtain separate
reimbursement.
o The CMS/CCI guidelines indicate that the use of a separate incision or separate
surgical approach alone is not sufficient when the more comprehensive procedure
is performed on an anatomically related area.
 Both codes are performed during the same operative session, but by different providers.
o Separate procedure bundling and guidelines apply to assistant surgeon, cosurgeon, and/or other situations involving multiple surgeons during the same
surgical session.
o It is not appropriate to use modifier XP or 59 to bypass separate procedure
bundling during the same operative session.
 The CCI procedure-to-procedure (PTP) edit is not eligible for a modifier bypass (modifier indicator of “0”).


For Example:
58805 “Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal
approach.”
This separate procedure may not be reported in combination with other procedure codes for
fallopian tubes, ovaries, or other female organs on the same date of service during the same
surgical session. Procedure codes for female organs are considered anatomically related.


Codes and Definitions


Modifier Definitions
Modifier Modifier Definition
Modifier XE Separate Encounter, A Service That Is Distinct Because It Occurred During A
Separate Encounter
Modifier XS Separate Structure, A Service That Is Distinct Because It Was Performed On A
Separate Organ/Structure
Modifier XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A
Different Practitioner
Modifier XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because
It Does Not Overlap Usual Components Of The Main Service




Modifier 59 Distinct Procedural Service: Under certain circumstances, it may be necessary
to indicate that a procedure or service was distinct or independent from other
non-E/M services performed on the same day. Modifier 59 is used to identify
procedures/services, other than E/M services, that are not normally reported
together, but are appropriate under the circumstances. Documentation must
support 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) not ordinarily encountered or performed on
the same day by the same individual. However, when another already
established modifier is appropriate it should be used rather than modifier 59.
Only if no more descriptive modifier is available, and the use of modifier 59 best
explains the circumstances, should modifier 59 be used.


Note: Modifier 59 should not be appended to an E/M service. To report a
separate and distinct E/M service with a non-E/M service performed on the
same day, see modifier 25.




Definition of Terms
Ipsilateral On the same side; affecting the same side of the body; the opposite of contralateral.
In paralysis, this term is used to describe findings on the same side of the body as the
brain or spinal cord lesions producing them.
Contralateral On the opposite side; originating in or affecting the opposite side of the body, the
opposite of homolateral and ipsilateral.




Coding Guidelines
“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/services provided at
that time, it may be reported by itself, or in addition to other procedures/services by appending
modifier 59 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).” (AMA1 )




“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.” (CMS2 )




“From an NCCI perspective, the definition of different anatomic sites includes different organs,
different anatomic regions, or different lesions in the same organ. It does not include treatment of
contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent
soft tissue constitutes treatment of a single anatomic site. Treatment of posterior segment
structures in the ipsilateral eye constitutes treatment of a single anatomic site. Arthroscopic
treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of
a single anatomic site.” (CMS3 )


References:
https://www.modahealth.com/pdfs/reimburse/RPM051