What are Mutually Exclusive Procedures in Medical Billing ?

Mutually Exclusive Procedure

Mutually exclusive procedures are defined as a set of procedures codes that cannot perform together. In other words, a Mutually exclusive procedure is based on the code definitions or anatomic considerations.

Under what circumstances two services be considered mutually exclusive?

  • The repair of the same organ but with two different methods. As a result, One repair method must be reported for the repairment.
  • When the Initial service and the subsequent service are reported together. It will be considered contradictory for a service to get classified as both an initial and subsequent service at the same time (with the exception of drug administration services).

Example for Inclusive 

Mr. Justin met with an accident injured the bones on his hand and underwent treatment and the Doctor installed a mechanical plate for smooth movement of bones. The Doctor Requested Justin to allow 7 days for the injuries to cure. Also, the surgeon insisted that Post seventh day the plate installed can be removed.

Now as instructed after completing the 7 days Justin came to the hospital and removed his plate and checked his injury status and went home. After someday, He received his bill but there are no charges added for the second visit for the removal of the plate. Hurray!! Justin is now happy and paid the amount for his first visit.

Do you have any answers? why the second visit was free??

Answer

The answer is the second visit is included in the primary service. This is to say, treatments in addition to the primary service within the same place will be included. services like plating, screw bolt removal, dressing, cleaning will be included in the primary service. Doctors cannot bill those services each and every time.

Example for Exclusive

Same as the previous Example the only difference is primary service includes the Doctor’s fee, Bed charge, surgical supplies, which are need for primary service. So, this has to be paid separately. In other words, it is called the Exclusive procedure to differentiate this respective Modifier should be added according to NCCI Edits.

Questionnaire for Mutually Exclusive Procedures

Mutually exclusive denial

Mutually Exclusive Procedures Recommended tips

In short, The important key point is to Check for the Primary CPT, and when you find it correctly paid rest of the addon codes will be included. The other scenario can have modifiers on the CPT to override NCCI edits. This is the case where the procedure is mutually exclusive and has to be separate.

Read moreCO 50 denial code (Not deemed a medical necessity by the payer)

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