Incidental or significant: What’s the difference?
By Lois Yoder, ART, CCS
Vice President of Product Development
Medical Learning, St. Paul, MN
[Editor’s note: To help our readers prepare for ambulatory patient groups (APGs), we’ve asked an APG expert to address some of your most common questions. If you have questions about APGs, write us, and we’ll answer them in the newsletter. Address them to: Joy Daughtery, Managing Editor, Same-Day Surgery, P.O. Box 740056, Atlanta, GA 30374. Fax: (404) 262-7837. E:mail: [email protected].]
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 defining incidental procedures exactly is a gray area under APGs. Payers vary on what they regard as incidental, and their guidelines aren’t always clear-cut. The reasons are that these services are not considered ancillary if they do not constitute the main reason for the visit. They also can occur as part of a significant procedure but aren’t payable as a separate one. 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 an electrocardiogram (EKG). Here again, EKGs qualify as incidental only when they are performed within the payer’s allowable time frame, or window. Determining the payment window for the procedure is important. It could vary between 24 hours and three days before or after a visit. Providers should consult with each payer to determine these time frames and ask about the defined incidentals. They usually are 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. Because they are either bundled or not covered, incidentals usually are not paid separately. But again, determine each payer’s payment practice.
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