CMS Pub. 100-04, ch. 12, § 30

B3-15068

The Correct Coding Initiative was developed to promote national correct coding methodologies

and to control improper coding leading to inappropriate payment in Part B claims. Refer to

Chapter 23 for additional information on the initiative.

The principles for the correct coding policy are:

• The service represents the standard of care in accomplishing the overall procedure;

• The service is necessary to successfully accomplish the comprehensive procedure.

Failure to perform the service may compromise the success of the procedure; and

• The service does not represent a separately identifiable procedure unrelated to the

comprehensive procedure planned.

For a detailed description of the correct coding policy, refer to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/How-To-Use-

NCCI-Tools.pdf.

The CMS as well as many third party payers have adopted the HCPCS/CPT coding system for

use by physicians and others to describe services rendered. The system contains three levels of

codes. Level I contains the American Medical Association’s Current Procedural Terminology

(CPT) numeric codes. Level II contains alpha-numeric codes primarily for items and services

not included in CPT. Level III contains A/B MAC (B) specific codes that are not included in

either Level I or Level II. For a list of CPT and HCPCS codes refer to the CMS Web site.

The following general coding policies encompass coding principles that are to be applied in the

review of Medicare claims. They are the basis for the correct coding edits that are installed in

the claims processing systems effective January 1, 1996.

A. Coding Based on Standards of Medical/Surgical Practice

All services integral to accomplishing a procedure are considered bundled into that procedure

and, therefore, are considered a component part of the comprehensive code. Many of these

generic activities are common to virtually all procedures and, on other occasions, some are

integral to only a certain group of procedures, but are still essential to accomplish these

particular procedures. Accordingly, it is inappropriate to separately report these services based

on standard medical and surgical principles.

Because many services are unique to individual CPT coding sections, the rationale for

rebundling is described in that particular section of the detailed coding narratives that are

transmitted to A/B MACs (B) periodically.

B. CPT Procedure Code Definition

The format of the CPT manual includes descriptions of procedures, which are, in order to

conserve space, not listed in their entirety for all procedures. The partial description is

indented under the main entry. The main entry then encompasses the portion of the description

preceding the semicolon. The main entry applies to and is a part of all indented entries, which

follow with their codes.

In the course of other procedure descriptions, the code definition specifies other procedures

that are included in this comprehensive code. In addition, a code description may define a

rebundling relationship where one code is a part of another based on the language used in the

descriptor.

C. CPT Coding Manual Instruction/Guideline

Each of the six major subsections include guidelines that are unique to that section. These

directions are not all inclusive of nor limited to, definitions of terms, modifiers, unlisted

procedures or services, special or written reports, details about reporting separate, and multiple

or starred procedures and qualifying circumstances.

D. Coding Services Supplemental to Principal Procedure (Add-On Codes) Code

Generally, these are identified with the statement “list separately in addition to code for

primary procedure” in parentheses, and other times the supplemental code is used only with

certain primary codes, which are parenthetically identified. The reason for these CPT codes is

to enable physicians and others to separately identify a service that is performed in certain

situations as an additional service. Incidental services that are necessary to accomplish the

primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy) are not

separately billed.

E. Separate Procedures

The narrative for many CPT codes includes a parenthetical statement that the procedure

represents a “separate procedure.”

The inclusion of this statement indicates that the procedure, while possible to perform

separately, is generally included in a more comprehensive procedure, and the service is not to

be billed when a related, more comprehensive, service is performed. The “separate procedure”

designation is used with codes in the surgery (CPT codes 10000-69999), radiology (CPT codes

70000-79999), and medicine (CPT codes 90000-99199) sections. When a related procedure

from the same section, subsection, category, or subcategory is performed, a code with the

designation of “separate procedure” is not to be billed with the primary procedure.

F. Designation of Sex

Inactivated as of October 1, 2024.

G. Family of Codes

In a family of codes, there are two or more component codes that are not billed separately

because they are included in a more comprehensive code as members of the code family.

Comprehensive codes include certain services that are separately identifiable by other

component codes. The component codes as members of the comprehensive code family

represent parts of the procedure that should not be listed separately when the complete

procedure is done. However, the component codes are considered individually if performed

independently of the complete procedure and if not all the services listed in the comprehensive

codes were rendered to make up the total service.

H. Most Extensive Procedures

When procedures are performed together that are basically the same or performed on the same

site but are qualified by an increased level of complexity, the less extensive procedure is

bundled into the more extensive procedure.

I. Sequential Procedures

An initial approach to a procedure may be followed at the same encounter by a second, usually

more invasive approach. There may be separate CPT codes describing each service. The

second procedure is usually performed because the initial approach was unsuccessful in

accomplishing the medically necessary service. These procedures are considered “sequential

procedures.” Only the CPT code for one of the services, generally the more invasive service,

should be billed.

J. With/Without Procedures

In the CPT manual, there are various procedures that have been separated into two codes with

the definitional difference being “with” versus “without” (e.g., with and without contrast).

Both procedure codes cannot be billed. When done together, the “without” procedure is

bundled into the “with” procedure.

K. Laboratory Panels

When components of a specific organ or disease oriented laboratory panel (e.g., codes 80061

and 80059) or automated multi-channel tests (e.g., codes 80002 - 80019) are billed separately,

they must be bundled into the comprehensive panel or automated multi-channel test code as

appropriate that includes the multiple component tests. The individual tests that make up a

panel or can be performed on an automated multi-channel test analyzer are not to be separately

billed.

L. Mutually Exclusive Procedures

There are numerous procedure codes that are not billed together because they are mutually

exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be

done in the same session.

An example of a mutually exclusive situation is when the repair of the organ can be performed

by two different methods. One repair method must be chosen to repair the organ and must be

billed. Another example is the billing of an “initial” service and a “subsequent” service. It is

contradictory for a service to be classified as an initial and a subsequent service at the same

time.

CPT codes which are mutually exclusive of one another based either on the CPT definition or

the medical impossibility/improbability that the procedures could be performed at the same

session can be identified as code pairs. These codes are not necessarily linked to one another

with one code narrative describing a more comprehensive procedure compared to the

component code, but can be identified as code pairs which should not be billed together.

M. Use of Modifiers

When certain component codes or mutually exclusive codes are appropriately furnished, such

as later on the same day or on a different digit or limb, it is appropriate that these services be

reported using a HCPCS code modifier. Such modifiers are modifiers E1 - E4, FA, F1 - F9,

TA, T1 - T9, LT, RT, LC, LD, RC, -58, -78, -79, and -94.

Modifier -59 is not appropriate to use with weekly radiation therapy management codes

(77427) or with evaluation and management services codes (99201 - 99499).

Application of these modifiers prevent erroneous denials of claims for several procedures

performed on different anatomical sites, on different sides of the body, or at different sessions

on the same date of service. The medical record must reflect that the modifier is being used

appropriately to describe separate services.