Mutually exclusive procedures in medical billing and coding fall into two basic categories. Using basic medical knowledge and common sense, the biller/coder can quickly learn to recognize potential problems.
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A procedure that can’t be done in combination with another: Because some procedures can’t be successfully performed together, they are not going to be paid on the same claim. Here’s an example (albeit an extreme one that helps explain the concept): Imagine that the patient has suffered severe damage to his arm. During surgery, the surgeon tries but fails to repair the arm and decides that amputation is necessary.
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You can’t code for both a fracture repair and an amputation if both occurred during the same session. Nor is the insurance company going to pay for both the fracture repair and amputation in this situation. If the amputation was deemed necessary, then that is the procedure you code and bill for.
However, if the physician repaired the fracture and then three weeks later the patient returned with severe necrosis (tissue death) and was becoming septic — a life-endangering condition — then the provider can bill both procedures.
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Procedures that are not possible under the present circumstances: This type of exclusivity relates to procedures that are age- or sex-related. Men do not give birth. Women do not have prostate procedures. Exclusivity may be defined as not possible under the presented circumstances.
