Navigating medical coding can be a challenge, especially when it comes to understanding when procedures and Evaluation & Management (E/M) services are separately billable. Three key concepts—separate procedures, global surgical packages, and E/M modifiers play a critical role in accurate and compliant billing. Let’s break them down.

Separate Procedures: When to Bill and When to Bundle

CPT® codes labeled as “(separate procedure)” are often misunderstood. These codes are typically bundled into more complex procedures and are not separately billable unless one of the following specific criteria is met:

• The separate procedure is the only procedure performed on that date.
• It was performed through a different incision.
• It involved a different anatomical site entirely.

Documentation Tip: If a separate procedure is performed alongside a more complex one, the operative or procedure report must clearly justify why it should be reimbursed separately. For example, if the procedure was done on a different limb or body area, that distinction must be documented clearly within the operative report.