An incidental procedure is carried out at the same time as a more complex primary procedure. These procedures require little additional provider resources and are generally not considered necessary to the performance of the primary procedure. For example, the removal of an asymptomatic appendix is considered an incidental procedure when done during hysterectomy surgery. An incidental procedure is not reimbursed separately on a claim.
Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure.
Procedures are considered mutually exclusive when:
** The procedures cannot reasonably be done in the same session
** The procedures represent two different methods to achieve the same result
** The procedures are reported as an initial and a subsequent service
Procedures are considered incidental (not an all-inclusive list) when:
** The procedure is clinically integral to the successful outcome of the primary procedure
** The procedure is performed through the same incision with a procedure of greater clinical intensity
** The procedure is designated a “separate procedure” by CPT
** The procedure is a surgical approach to a major surgical service
** The codes are reported separately as left and right procedures when one code exists that describes the same service as a bilateral procedure
** Component parts of a comprehensive service are reported separately when one code exists that describes the entire service
A procedure is not considered incidental when:
** It is performed alone
** Is not immediately related to other services
B. Mutually Exclusive Procedures
Mutually exclusive procedures are two or more procedures that are usually not performed on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedures for which the provider should be submitting only one of the procedure codes. Only the most clinically intense procedure will be allowed. Generally, an open procedure and a closed procedure in the same anatomic site are not both reimbursed. If both codes accomplish the same result, the clinically more intense procedure supersedes and the comparative code is denied as mutually exclusive.
A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive.
Generally, an open procedure and a closed and/or endoscopic procedure performed in the same anatomic site are not both reimbursed. If both procedures accomplish the same result, the clinically more intensive procedure is recommended for reimbursement and the less intensive procedure is considered mutually exclusive.
51925 Closure of vesicouterine fistula; with hysterectomy (paid)
57550 Excision of cervical stump, vaginal approach (denied as mutually exclusive)
47600 Cholecystectomy (paid)
49000 Exploratory laparotomy, exploratory celiotomy with or without biopsy(s)
(separate procedure) (denied as incidental)
INCIDENTAL PROCEDURE EDIT DEFINITION
Incidental procedures require little additional provider resources and are not generally considered necessary to the performance of the primary procedure. An incidental procedure is not reimbursed separately on a claim. Incidental services includes procedures that can be performed along with the primary procedure but are not essential to complete the procedure. They do not typically have a significant impact on the work and time of the primary procedure. Incidental procedures are not
separately reimbursable when performed with the primary procedure.
EXAMPLES RELATED TO REIMBURSEMENT
Example: Billing the following procedures together: 44005 – Enterolysis (surgical separation of intestinal adhesions, separate procedure) & 44140 – Partial colectomy with anastomosis (primary procedure)
NCCI Correct Coding: Separate procedures are not reported in addition to the total procedure or service – Line item denial of procedure 44005 and reimbursement in full of line item 44140
Example: Billing the following procedures together: 47120 – Hepatectomy, resection of liver, partial lobectomy & 47371 – Laparoscopy, surgical, ablation of one or more liver tumor(s); cryosurgical NCCI Correct Coding: 47371 is considered incidental to the primary procedure 47120. Line item denial of procedure 47371 and reimbursement in full of line item 47120
C. Integral Procedures
Procedures considered integral occur in multiple surgery situations when one or more of the procedures are included in the major or principle procedure. Integral procedures are those commonly carried out as part of a total service and do not meet all the criteria listed under the policy “Multiple Surgical Procedure Guidelines.” Some of the procedures or services listed in the CPT manual that are commonly carried out as an integral component of a total service or procedure have been identified by the term “separate procedure.” These codes should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.
D. Global Allowance
Most medical and surgical procedures include pre-procedure, intra-procedure, and postprocedure work. Reimbursement for these services is based on a global allowance. Claims for services considered to be directly related to pre-procedure, intra-procedure, and post-procedure work are included in the global reimbursement and will not be paid separately. The pre- and post-operative global days are based on CMS standards. The global period is defined as the period of time during which claims for related services will be denied as an unbundled component of the total surgical package. Major procedures have a global period of 90 days. Minor procedures have a global period of 10 or 0 days. The global surgical package includes all necessary services normally furnished by the surgeon before, during and after a surgical procedure. The global period also includes Evaluation and Management services that are related to the procedure. Payment for related medical or surgical services performed the day prior to, the day of, or within 90 days of a major surgical procedure is included in global allowance. Payment for related medical or surgical services performed the same day as a minor surgical procedure, as well as medical or surgical services performed within 10 days of a 10 day procedure, is included in the global allowance. Global surgery guidelines also apply to facility claims. See also, “Guidelines for Global Maternity Reimbursement.”
Bundling Guidelines with examples
A facility credentialed and contracted as an urgent care center cannot submit claims for after hours care. CPT codes 99050 and 99051 are considered mutually exclusive to any service(s) provided at an urgent care center.
Service(s) provided between 10:00 PM and 8:00 AM at a 24-hour facility, in addition to basic service (99053), is considered incidental to Evaluation and Management services, Surgical services, and Laboratory services and are not eligible for separate reimbursement.
Office services provided on an emergency basis (99058) are considered mutually exclusive to the primary services provided.
Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service (99060) is considered incidental to Evaluation and Management services, Surgical services, and Laboratory services and are not eligible for separate reimbursement. Anesthesia: Anesthesia provided by the operating physician is considered incidental to the surgical procedure. This includes sedation given for endoscopic procedures including, but not limited to, colonoscopy.
Anesthesia complicated by emergency conditions: (Add-on code 99140) is considered incidental to the procedure/administration of anesthesia.
Anticoagulant management for a patient taking warfarin (93793) is not eligible for separate reimbursement.
Balloon Sinuplasty: Balloon sinuplasty (codes 31295, 31296, 31297, 31298) performed in conjunction with functional endoscopic sinus surgery (FESS) within the same sinus cavity, is considered incidental to the major service and not eligible for separate reimbursement. Refer to policy “Surgical Treatment of Sinus Disease.”
Bone Marrow or Stem Cell Services/Procedures: Codes 38204, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214 and 38215 are considered incidental to 38240, 38241 and 38242. Cardiac Stress Test: A stress test may require the administration of pharmacological agents. An IV injection of a pharmacological agent is considered an integral component of the stress test and does not warrant separate reimbursement.
Care Management Services which include complex chronic care management (99487, 99489), chronic care management (99439, 99490, 99491, G0506), transitional care management (99495, 99496), cognitive assessment and care plan services (99483, 99484), psychiatric collaborative care management (99492, 99493, 99494, G2214) are not eligible for separate reimbursement.
“Incident to” Services: CMS defines “incident to” services as those services furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of a condition. A physician may be reimbursed directly for “ incident to” services performed
by auxiliary personnel only when an employer relationship exists between the physician and the auxiliary personnel, and when the place of service code indicates the service was performed at a location typical for such an employer relationship (typically a physician office or other non-facility clinic). When the place of service code indicates the service was performed at a location not typical of a physician employer relationship (such as, but not limited to, inpatient or outpatient hospital), the service is considered an “incident to” service and is not eligible for separate reimbursement. In the unusual circumstance when an employer relationship exists between the physician and auxiliary personnel performing a service in an inpatient or outpatient facility, documentation of this arrangement could be submitted for reconsideration.