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

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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.

 

First Published:06/01/2007
Latest Revision:01/29/2008
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