F. Designation of Sex
Many procedure codes have a sex designation within their narrative. These codes are not billed with codes having an opposite sex designation because this would reflect a conflict in sex classification either by the definition of the code descriptions themselves, or by the fact that the performance of these procedures on the same beneficiary would be anatomically impossible.
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.
