Incidental or significant What’s the difference?
Question: What constitutes an "incidental procedure" as opposed to a significant one for payment purposes? Does an incidental procedure pay less? If so, by how much?
Answer: An incidental procedure is one that occurs within a payer’s payment window but is not considered integral to the visit or procedure. Beyond that, the issue of exactly defining incidental procedures is presently a gray area under APGs. Payers vary on what they regard as incidental, and their guidelines aren’t always clear-cut.
The reasons for this are that these services are not considered ancillary if they do not constitute the main reason for the visit. They can also occur as part of a significant procedure but aren’t payable as a separate procedure.
Services are more complex
For example, a lysis of adhesions (CPT-4 56304) during a laparoscopic procedure is typically deemed incidental to the laparoscopy. The payer is likely to identify the lysis as incidental to the surgery if you code the procedure separately on the claim.
Other characteristics that generally define incidental procedures may include the following:
• A minor procedure serving to complete a significant procedure. For example, a layered closure of subcutaneous tissue (CPT 12034).
• A routine procedure performed by a physician that coincides with a significant procedure. For example, an excision of a lipoma with inguinal hernia repair (CPT 55520).
• Services that are more complex and require more time than most diagnostic testing.
One of the most common incidental procedures under APGs is electrocardiograms (EKGs). But here again, EKGs qualify as incidental only when they are performed within the payer’s allowable time frame, or window, for payment.
Payment window varies by procedure, payer
Determining the payment window for the procedure is important. A payment window could vary between 24 hours and three days either following or prior to a visit. Providers should consult with each payer to determine these time parameters and inquire about the list of defined incidentals. They are usually not listed on the provider agreement, so check with each payer.
Many times, the incidental procedures are bundled for payment under the significant procedure code according to the health plan’s policy. And because they are either bundled or not covered, incidentals usually do not get separately paid. But again, determine each payer’s payment practice.
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