Surgical Services from the 40000 Series of CPT Billed with Other Services

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 visit (E/M), 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 40000 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 criteria for the use of the modifier are met.

Codes from the 40000 series billed with other codes from the same series

Note: A number of codes in the 40000 section are also subject to HMSA's Multiple Endoscopy Procedures policy.

Codes from the 40000 series billed with other codes from the Surgery and Radiology sections

Codes from the 40000 series billed with codes from the Medicine section

Codes from the 40000 series billed with Evaluation and Management services

Notes:

1. The above lists are not all inclusive and are subject to change.
2. When this procedure is billed with an office visit, HMSA's current claims processing system will allow payment only of the higher-valued code. Under the new system, both may be paid if criteria are met for the use of an appropriate modifier code.

Revision History