Surgical Services from the 10000 Series of CPT Billed with Other Services

HMSA is in the process of upgrading its claims processing system for private business claims. During the transition from old system to new, some claims will process using HMSA's existing edits and others will process using the new claims processing system with Ingenix edits. Because HMSA is transitioning to a new system, it does not plan to incorporate the policy changes into the old system. As a result, providers may notice small variations in processed claims, depending on whether the old system or the new system was used for processing.

 

The guidelines described below apply to claims processed under the new claims processing system. The guidelines should be used for filing all private business claims.

 

The code edit changes described in the guidelines below will not override HMSA's existing medical policies.

 

Modifiers

When billing for surgical services with other services, it is important to bill accurately.

 

When the surgical code is billed with an Evaluation & Management (E/M) visit, a modifier code must be appended to the E/M code to ensure that both services are paid when appropriate. The following modifiers may be used for this purpose: 24, 25 and 57.

 

Modifier Code 25

Modifier Code 57

Preoperative Visits

Postoperative Visits

 

When two or more surgical codes are billed together, a modifier code(s) must be appended to one or more of the surgical codes. Modifiers that may be used include 51, 58, 59, 76, 78, 79, LT, RT and other site specific modifiers. Practitioners are urged to familiarize themselves with the criteria listed in CPT and in the following policies.

 

Modifier Code 59

Modifier Code 76

Modifier Codes 78 and 79

Multiple Surgical Procedures

 

Modifier codes should only be used when the service meets the criteria described in CPT and HMSA's policies. HMSA will perform postpayment reviews of modifier usage as needed to verify modifiers were used as described. If postpayment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment. See Benefit Overpayment.

 

Specific Edits

The following code edits apply to surgical services from the 10000 series of CPT billed with other services.

 

If the code in the left column is billed with any of the codes in the right column, one of the codes will deny. The reason for the denial may vary because:

• The codes may be mutually exclusive. Mutually exclusive procedures are two or more procedures that are usually not performed during the same patient encounter on the same date of service.
• Multiple codes may have been billed, which taken together are more accurately described by a more comprehensive procedure code.
• The code may be incidental to another code. An incidental procedure is a procedure carried out at the same time as a more complex primary procedure; however, the incidental procedure requires little additional physician resources and/or is clinically integral to the performance of the primary procedure.

 

However, unless otherwise indicated, a modifier may be used to request separate payment if the criteria for the use of the modifier are met.

 

Codes from the 10000 series billed with other codes from the same series

 

CPT Code(s)	CPT Code(s)
10040	10060-10061, 11100
10060	10040, 11730
10060	11400-11646
10061	10040
11011	12036
11040-11042	11721
11055-11057	11720-11721, 17110
11100	11040, 11200, 11300, 11400, 11441, 11602, 11604, 17000-17004, 17260-17263, 17270-17274, 17280
11101	11600-11603, 11606-11624, 11640-11643, 11646, 17000-17003, 17260-17264, 17270-17274, 17304-17306
11200	11100, 11300-11301, 11310, 17110
11300	11100, 11200, 17000-17003
11301	11200, 17000
11305-11307	17000-17003
11310	11200, 17000-17003
11312	17000-17003
11400-11646	10060
11400	11100, 12032, 12041, 14000, 17000-17003
11401-11402	17000-17003
11421	17000-17003
11440	17000
11441	11100
11442	17000-17003
11446	17003
11600-11601	11101
11602	11100, 11101, 17000-17003
11603	11101
11604	11100
11606-11621	11101
11622	11101, 17003
11623-11624	11101
11640-11641	11101
11642	11101, 17000-17003
11643	11101
11646	11101
11720	11055-11057
11721	11040-11042, 11055-11057
11730	10060
11900-11901	17000,17004

 

12032	11400
12036	11011
12041	11400
12051	14060
14000	11400
14060	12051
17000	17004 Note: This code combination will not be paid, even if billed with a modifier. The codes are mutually exclusive.
17000	11100-11101, 11300-11301, 11305-11307, 11310, 11312, 11400-11402, 11421, 11440, 11442, 11602, 11642, 11900-11901, 17260-17263, 17271, 17280-17281
17003	17004 Note: This code combination will not be paid, even if billed with a modifier. The codes are mutually exclusive.
17003	11100-11101, 11300, 11305-11307, 11310, 11312, 11400-11402, 11421, 11442, 11449, 11602, 11622, 11642, 17260-17263, 17271-17272, 17280-17281
11704	17000, 17003 Note: This code combination will not be paid, even if billed with a modifier. The codes are mutually exclusive.
17004	11100-11101, 11900-11901, 17261-17262, 17281
17110	11055-11057, 11200, 17111 (see note below)
17111	17110 Note: This code combination will not be paid, even if billed with a modifier. The codes are mutually exclusive.
17260	11100-11101, 17000-17003
17261-17262	11100-11101, 17000-17004
17263	11100-11101, 17000-17003
17264	11101
17270	11100-11101
17271	11100-11101, 17000-17003
17272	11100-11101, 17003
17273-17234	11100-11101
17280	11100, 17000-17003
17281	17000-17004
17304-17306	11101
19102	19103
19103	19102
19316	19342
19342	19316

 

Codes from the 10000 series billed with other codes from the Surgery section

 

CPT Code(s)	CPT Code(s)
38505	10021
40490	11100-11101
67810	11101

 

Codes from the 10000 series billed with codes from the Medicine section

 

CPT Code(s)	CPT Code(s)
90772	10060-10061, 10120-10121, 10160, 11300-11303, 12001-12002, 12032, 17000, 17004
90774	10060, 16025

 

Codes from the 10000 series billed with Evaluation and Management services

 

Service Description	CPT Code(s)
Established patient office visits	10060, 10160, 17000, 17003, 17250, 17340
Office/outpatient consultations	10060, 10160, 11100, 11750, 12002, 12011, 17110, 19000
Preventive service exams for established patient	10060

 

Codes from the 10000 series billed with HCPCS code G0168

 

HCPCS Code	CPT Code(s)
G0168	12001-12002, 12004-12007, 12011, 12013-12018

 

Note: The above lists are not all inclusive and are subject to change.