Chapter 5 Flashcards
CPT
Pg. 58
E/M: Evaluation & Management Codes
Divided into Categories
*Place of service
*Type of service
*Subcategories indicate specific details (new or established patient)
*Subcategories divided into levels, assigned five-digit code
Decision Tree for New vs Established patient..
If patient has seen another provider, in the same group, of the same specialty, within three years, the patient is established.
A transition from observation status to inpatient is not considered a new stay…
Likewise, a transition between nursing facility and skilled nursing facility is not considered a new stay.
E/M Evaluation & Management
MDM
MDM = Medical Decision Making.
Codes for new vs established are based on medical decision making (which for a new patient MDM takes more time) therefore different pay and different codes are used. Also, total time of the encounter determines the code.
Level of E/M
Look at las digit of the code:
Level 3 is Office Visit (99213)
Level 2 Consultation (99242)
For E/M to qualify as a Consultation…
*service request by another provider
*render an opinion or recommendation
*respond to the requesting provier.
Medicare and some commercial payers do NOT…
reimburse for consultations. CMS recommends reporting new vs established codes.
For purpose of CPB exam…
examinee will be expected to determine codes based on levels of time (given) and should recognize which E/M code is associated w/ given levels (MDM and Time will be given on exam)
E/M MDM and Time…
E/M Code: 99202 99213
MDM straightforward Low
Time 15-29 minutes 20-29 min
*patient seen; MDM and low complexity; 25 minutes… correct code is 99213
bcuz when using total time on DOS, 20 minutes must be met.
A patient is seen in the ED (ER) after having an auto accident. The patient is new to this provider. What subcategory of E/M is reported?
Answer: D. Emergency Department Services
Rationale: The patient is being seen in the emergency department and has not been admitted to the hospital. Look in the CPT® Index for Evaluation and Management/Emergency Department which directs you to codes 99281–99285
A patient is seen by his family provider at the provider’s office. The patient last saw the provider four years prior. Which range of codes would a code be selected from?
Answer: B. 99202–99205
Rationale: The patient has not seen the provider in over three years. Look in the CPT® Index for Evaluation and Management/Office and Other Outpatient which directs you to 99202–99215. In the Evaluation and Management section of the CPT® code book, the Office and Other Outpatient codes are further broken down into new and established patient. New patient codes are reported from the range 99202–99205.
3.A patient is admitted to the hospital for observation on date of service 01/02/XX and discharged from observation on date of service 01/03/XX. Which range of codes would the code(s) be selected from for the admit and discharge from observation?
Answer: A. Admit 99221–99223; Discharge 99238–99239
Rationale: The patient was admitted to observation on one day and discharged the next. Look in the CPT® Index for Evaluation and Management/Hospital Services/Inpatient or Observation Care/Initial and you are directed to 99221-99223. Look in the CPT® Index for Evaluation and Management/Hospital Services/Inpatient or Observation Care/Discharge Day Management and you are referred to 99238, 99239. Admission is reported from the range of the Initial Inpatient or Observation Care (99221–99223) and the discharge, because it was on a different date of service, is reported from the Inpatient or Observation Care Discharge Day Management (99238, 99239). If the patient was admitted and discharged on the same date of services, one code would have been selected from code range 99234–99236.
4.A patient is seen for a follow-up visit in the hospital. A medically appropriate history and exam, and MDM of low complexity were documented. What E/M code is reported?
Answer: C. 99231
Rationale: A follow-up visit in the hospital is coded as subsequent hospital care. Look in the CPT® Index for Evaluation and Management/Hospital Service/Inpatient or Observation Care/Subsequent and you are directed to 99231–99233. Because there is a low medical decision making, the level of service reported is 99231.
5.A 43-year-old established patient is seen for his annual preventive exam by the family physician. A medically appropriate history and exam, and medical decision making of low complexity are performed. What E/M code is reported?
Answer: B. 99396
Rationale: Look in the CPT® Index for Evaluation and Management/Preventive Services and you are directed to 99381–99429. Established patient preventive services are reported from range 99391–99397. The patient is 43 making 99396 the correct code.
Pg. 62
Anesthesia CPT Codes
An-Es-Thee-Sha
*00100-01999
*Anesthesia is coded for the associated surgical procedure.
*Organized by anatomic regions.
Three types of anesthesia…
An-Es-Thee-Sha
General (loss of consciousness)
Regional (region of body)
MAC Monitored Anesthesia Care
Spinal Anesthesia
An-Es-Thee-Sha
CSF in spinal canal for surgeries below upper abdomen.
Epidural Anesthesia
An-Es-Thee-Sha
in the epidural space
Nerve Block
area around nerve to block sensation for the region.
MAC Monitored Anesthesia Care…
An-Es-Thee-Sha
Pt. under light sedation or no sedation w/ local anesthesia, monitored by Anesthesiologist who is prepared to convert MAC. to general.
MAC = Medicare Administrative Contractor in CA it’s Noridian in CO it’s Novitace
Anesthesia reported using CPT
An-Es-Thee-Sha
and time that the anesthesia services were provided. Time reported in minutes.
Payment for anesthesia services…
An-Es-The-Sha
calculated using
*base units associated with each code.
*the time (15 minutes) for one unit
*and modifying units
*units multiplied by a conversion factor or dollar amount.
Selecting an anesthesia code…
An-Es-Thee-Sha
follow same basic steps as procedure codes for other specialties. Use AI, locate anatomic area.
To look for the anesthesia code for a percutaneous liver biopsy, you can look in the CPT® Index or in the Anesthesia section of the CPT® code book.
An-Es-Thee-Sha
In the CPT® Index
– Anesthesia
Biopsy
Ear 00120
Liver 00702
Salivary Glands 00100
The correct code 00702
modifiers that are specific to anesthesia codes
An-Es-Thee-Sha
*P1–P6 are physical status modifiers that designate the general health status of the patient.
four anesthesia codes that are add-on codes that are used to identify specific qualifying circumstances,
An-Es-Thee-Sha
*extreme age 99100
*total body hypothermia 99116
*controlled hypotension 99135
*emergency conditions 99140
**if the qualifying circumstance is part of the CPT code description, the qualifying circumstance is NOT reported. EXAMPLE:
00834 - Anesthesia for hernia repairs in the lower abdomen not otherwise specified, younger than 1 year of age.
HCPCS (Hick-Picks) Level II Modifiers…
Modifiers - To report circumstances surrounding the various methods of anesthesia.
*did anesthesiologist perform the anesthesia.
*or provided medical direction
To apply the correct modifiers for anesthesia… the types of providers must be understood.
Anesthesiologist is a physician licensed to practice medicine and has completed anesthesiology program.
CRNA: Certified RN Anesthesiologist who has completed an accredited anesthesia training program.
Anesthesiologist Assistant: (should be spelled out bcuz AA already taken)
has completed accredited program. may only be directed by an anesthesiologist.
Anesthesia Resident: completed medical degree. In a Residency program.
SRNA: Student Registered Nurse Anesthetist
Modifiers reported w/ anesthesia CPT codes.. An-Es-Thee-Sha
AA - Anesthesia by Anesthesiologist
AD - Anesthesia Directed by Dr
GC - Resident
QK - Direction is concurrent by Dr
QX - CRNA w/ Direction
QY - Direction of ONE CRNA
QZ - CRNA w/o direction
AA - Anesthesia by Anesthesiologist
AD - Medical supervision by a physician.
QK- Medical direction of 2,3, or 4 concurrent procedures. (concurrent means all current ongoing cases)
QY- Medical direction of one CRNA
GC- Resident
QX- CRNA w/ medical direction.
QZ-CRNA w/o medical direction.
State scope of practice may prohibit claims w/ a non-medical direction modifier.
Medical Direction modifiers for anesthesia
An-Es-Thee-Sha
are reported in the first position after the CPT code bcuz payment is related to the modifier. Other modifiers are reported second position after medical direction modifiers.
If more than one surgical procedure is performed during a single anesthetic…
the most complex procedure (highest unit value) is reported.
Surgery CPT codes describe a package of services…
*Local (nerve blocks)
*One E/M
*Post Op
*talking w/ fam & other physicians
*Post Op follow up.
Follow-up services (after surgery) have a global period.
Medicare:
*0 days,
*10 days (minor surgery)
*90 days (major surgery)
Many payers adopt Medicare global periods. (this used in the CPB exam)
To determine the global period..
the Medicare Physician Fee Schedule can be referenced. MPFS
Global Days Status Indicators 000
meaning ….
000 - is for …
Minor procedure w/ PreOp PostOp.
E/M on day of procedure NOT payable.
Global Days Status Indicators 010
*Minor procedures
*Pre-Op Day of
*10 day Post-op.
*E/M NOT paid on day of and 10 day f/u
Global Days Status Indicators 090
*Major procedure.
*One day Pre-Op
*90 Days Post-Op
*E/M NOT paid for day of, day prior and day of surgery.
Global Days Status Indicator for MMM
Maternity codes
*global period does NOT apply
Global Days Status Indicator for XXX
Global… Does NOT apply.
E/M, Anesthesia, Lab & Radiology.
Global Days Status Indicator for YYY
these are unlisted codes, and subject to individual pricing.
Global Days Status Indicator for ZZZ
These are add-on codes. They are related to another service and included in the global period.
Care required due to complications, exacerbations, recurrences…
may be separately reported.
Medicare will only reimburse separately for Post Op if
complications that result in a return to the OR.
When multiple procedure are performed
*Report major procedure w/ CPT code
*Additional procedures use modifiers
*Modifier 51
TIP: Some payers request modifier 51 not be appended as the payers processing system is programmed to automatically append modifier 51 to subsequent procedures. It is necessary for a medical biller to know the policies of their payers.
Follow-up care … is
care related to recovery from the procedure. Care for underlying condition is not included in follow up.
Codes with plus sign symbol are
add-on codes. Add-on codes should never be reported without a parent code.
Example
15260Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less
+15261each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
“Separate procedure” in the code descriptor…
*Does NOT mean bill separately.
*if the procedure…. is performed as part of another procedure …. that typically includes the “separate procedure” then separate reporting of the “separate procedure” code is INCORRECT.
Surgical procedures often found in the CPT Index under anatomic location or under procedure..
The code for a liver biopsy can be found in the CPT® Index under Biopsy/Liver which directs you to 47000, 47001, 47100, 47700.
Biopsy
Liver 47000, 47001, 47100, 47700
You can also look under Liver/Biopsy
It’s very important to read the section guidelines and parenthetical instructions in the surgical section …
bcuz they give guidance on correct coding procedures.
Guidance 1.
Each lesion excision is reported …
separately while the length of multiple repairs within the same anatomic section are added together.
Guidance 2.
a diagnostic endoscopy or arthroscopy …
is always included when performed w/ a surgical endoscopy or arthroscopy respectively.
Example of Guidance 2.
a diagnostic endoscopy or arthroscopy…
29800Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
29804Arthroscopy, temporomandibular joint, surgical
CPT® code 29800 is inclusive to CPT® code 29804 and is not reported separately.
Guidance 3.
Some interventional codes have
supervision and interpretation included in the procedure. the imaging codes are NOT reported in addition to the procedure code.
Guidance 4
sometimes, the use of modifiers…
is included in the section guidelines.
Guidance 5
Coding guidance may also be found in
parenthetic instructions
Review 5.3
What is the CPT® code for anesthesia performed for surgical arthroscopy on the ankle?
Answer: B. 01464
Rationale: Look in the CPT® Index for Anesthesia/Arthroscopic Procedures/Ankle and you are directed to 01464. Verify code selection in numeric section of the CPT® code book.
Review 5.3
Anesthesia procedures 00830 (4 base units) and 00832 (6 base units) are both performed. How are these reported on the claim form?
Answer: D. 00832 with the time units for both procedures
Rationale: When reporting multiple anesthesia procedures during one surgical session, the anesthesia code with the most anesthesia base units is reported with the time units for both procedures.
Review 5.3
What CPT® code is reported for a diagnostic proctosigmoidoscopy?
Answer: A. 45300
Rationale: Look in the CPT® Index for Proctosigmoidoscopy/Diagnostic which directs you to 45300. Verify code selection in the numeric section of the CPT® code book.
Review 5.3
What guidance is found under CPT® code 64492?
Answer: D. Use 64492 in conjunction with 64490, 64491
Rationale: In the CPT® code book, code 64492 has a parenthetic instruction to assist in coding:
(Use 64492 in conjunction with 64490, 64491)
Review 5.3
Which reporting option below is correct for CPT® code 69424?
Answer: A. 69424-50
Rationale: In the CPT® code book, code 69424 has two parenthetic instructions to assist in coding:
(For bilateral procedure, report 69424 with modifier 50.)
(Do not report 69424 in conjunction with 69205, 69210, 69420, 69421, 69433–69676, 69710–69745, 69801–69930.)
CPT Codes in 70000 range describe
Radiological services
Radiology designated as
radiological supervision and interpretation.
*If single provider performs the interventional procedure and radiological services, that provider may submit both codes.
Radiology codes can be divided into
*Technical Component use TC modifier
*Professional component designated with modifier 26.
Entity who owns equipment used to perform the service files claim for
TC Technical Component.
Professional interpreting the image claims the Professional Component.
If the same Radiology provider owns the equipment and provides the interpretation …
The global service is reported without a modifier.
Example
HCPCS Code with Modifiers
*72020-26 Interpretation Only
*72020-TC Performed the x-ray
In the CPT Index, some imaging can be found under location being imaged …
also found in X-ray, CT Scan, Magnetic Resonance Imagin MRI
When coding radiology services …
need to know which views and how many views are taken. many codes are based on views.
For Radiology also note contrast …
code options for contrast, without contrast, and without contrast followed by with contrast.
CPT guidelines “with contrast”
(special dye called contrast medium)
to evaluate structures that are not clear with conventional x-rays.
contrast administered
*Intravascular (artery or vein)
*intra-articular (joint)
*Intrathecally (spinal cord)
Oral and rectal contrast …
do not qualify as a study “with contrast”
Laboratory
CPT codes in the 80000 range
*for panels
*do NOT include collection
*Sometimes the collection is considered inclusive to office visit.
Laboratory
CPT contains approx 10 panels w/ combination of tests…
*if not exact match in the panel
*additional tests reported individually
Codes for anatomic, cytological and surgical pathology services may …
be divided into technical and professional components.
Similar to radiological…
Owner of lab equipment claims the technical component, while provider interpreting results of test claims the professional component.
Codes for this section can be found in the CPT Index under Pathology and Lab
Medicine section includes
*immunization
*pshychiatric
*dialysis
*cardiovascular (catheterization, angioplasties stent placement. implantable devices
*allergy tx
*neurological testing
*intravenous infusion
*physical medicine
*rehab services
Modifiers are appended (attached) to CPT and HCPCS Level 11 Codes
*to report specific circumstances, service, medical equipment w/o changing definition of code.
Modifiers are
two-digit codes
Appendix A
HCPCS Level 11
are in Appendix B of HCPCS code book
On codes w/ more than one modifier
*list functional or pricing modifiers in the first position.
*next informational modifiers; these clarify aspects of procedure/service
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Modifiers affecting payment include
*Procedures w/ professional & technical
(but only one inc. in the claim)
*more than one provider performed the procedure.
*Procedures that were increased or decreased from usual procedure
*multiple different procedures during same session
*single procedure performed more than once during same session
*single procedure performed bilaterally
Modifier 22
The service provided is greater than usually required for the procedure. Documentation must support the substantial work and reason for additional work “above and beyond” and there is no other code.
Modifier 22 is NOT
appended to E/M codes.
Examples of appropriate Uses of Modifier 22
*Excessive blood loss during procedure
*Excessive large surgical specimen.
*Trauma complicated procedure.
*Other pathologies, tumors, malformation that interferes with procedure.
Inappropriate Uses of Modifier 22
*Increased time provider variation
*Another code exists that covers the increased work.
key words: extended time, took longer than normal, extenuating circumstances.
Modifier 24
Use For:
*E/M unrelated service to the surgical procedure.
*E/M service performed during Post-Op period … reasons unrelated to original procedure.
*Insurance Carrier Specific. Some Ins. allow the use of Mod24 due to a complication of the surgical procedure.
Inappropriate uses of Modifier 24 during the initial post op unless…
*Immunosuppressive therapy
*Chemotherapy
*Critical care services unrelated to the surgery.
Modifier 25
On the day of procedure or service… patient’s condition required a significant, separately E/M service “above & beyond” the other service.
Appropriate use of Mod25
*With E/M codes for initial service… on the same day… a separate service, such as dialysis, that would NOT require E/M services.
*When significant, separately E/M service performed, on same day as a preventive care visit, the E/M must be for a NON preventive reason and documented.
Inappropriate uses of Mod25
*E/M resulted in decision to perform a major surgery (see Modifier 57)
*On surgical code.. it’s added to the E/M code when both are performed together.
*Office visit E/M code when primary reason for visit is for minor surgery.
Modifier 25 is under constant evaluation by payers for its misuse.
Keywords:
unrelated
outside of
not related to
Mod 25 is commonly misused. Work w/ coder … to determine if documentation supports an E/M visit separate from the surgical procedure performed.
Modifier 26
When the professional component is reported separately, id it by adding Modifier 26 to the code…
Appropriate uses:
*Imaging Co use TC Technical Component
*Professional services interpretation of images.
Inappropriate uses of Mod 26
(Global)
Using TC and Professional together. If same provider performs both services it’s considered global.
Using modifier when re-reading a study interpreted by another provider. Most insurances only pay for a single interpretation.
Modifier 50
Bilateral Procedures
some insurances require the cpt code be reported twice w/ Mod50 added to one of the codes.
Not all procedures can be reported w/ Mod50. Some codes say “unilateral or bilateral” indicating the code is used only once even if procedure performed on both sides.
Appropriate use of modifier 50
*exact same service bilaterally
*MPFS Medicare Physician fee Schedule indicate CPT can be reported w/ Mod 50
*Medicare recognizes Mod 50 on Radiology when study performed on each side. NOT all insurances allow this modifier combo.
Inappropriate Uses of Mod 50
*Bilateral on different areas of the body
*on bilateral procedure … if it’s part of description of code used.
*on unilateral … if it’s in the description of code used.
Page 68
Modifier 51
is for multiple procedures, other than E/M, Physical Medicine & Rehab, or provision of supplies are performed at the same session, same provider.
Append Modifier 51
for multiple instances of the same service … each service on separate line and does not require Modifier 59
Inappropriate uses of Modifier 51
*separating procedures
*unbundling procedures into its components
*appending Mod 51 to add-on codes that are Mod51 exempt
*appending to E/M code
Modifier 52
*for reduced or eliminated services associated with the code to which modifier is appended.
Inappropriate uses of Mod 52
*Indicate terminated procedure (Mod53)
*Appended to E/M services
*Appended to time-based services, such as psychotherapy, anesthesia, critical care.
Modifier 53
Discontinued Procedure.
*Procedure started, but d/c
bcuz of extenuating circumstances, threaten well-being of patient such as
uncontrollable bleeding, hypotension, physiologic changes, unexpected findings, anesthesia complications.
Inappropriate use of Mod 53
Elective cancellation of a procedure prior to anesthesia.
Modifiers 54, 55, 56
Preoperative (Mod 56)
Intraoperative (Mod 54)
Postoperative (Mod 55)
To indicate different providers provided
Preoperative (Mod 56)
Intraoperative (Mod 54)
Postoperative (Mod 55)
Only appended to codes that have a global period.
For procedures w/o global period (zero days), pre and post op are reported separately w/o modifiers.
Appropriate uses of Mod 54
*Provider performed only surgical procedure.
*If provider didn’t do the Pre-Op, then only append Mod 54 and 55
Inappropriate uses of Mod 54
*Appending mod 54 w/o global period
*Appending mod 55 Post-Op by a provider of a different specialty.
*Appending mod 54, 55 ,56 to an E/M code.
Keywords:
Modifier 54 Keywords: only performed the surgical procedure, no pre or post-op management, etc.
Modifier 55 Keywords: post-op follow-up only, postoperative care turned over to, transfer of care, etc.
Modifier 56 Keywords: pre-op evaluation only, covering for surgeon, etc.
Modifier 57 Decision for surgery:
*When E/M done the day before or day of surgery results in the decision to perform surgery, append Mod 57.
*Medicare and most Ins only recognize modifier 57 “day before or day of” which has a 90-day global period.
When decision for surgery occurs during the global period of a previous surgery….
append both Modifier 24 and Modifier 57 to the E/M code.
Modifier 58 for staged or related procedures.
To indicate a procedure or service during the Post-Op period was
*Planned at the time of original (staged)
*More extensive than the original procedure
*For therapy following a diagnostic procedure (related)
Appropriate use of Mod 58
*Patient planned to have the second procedure
*Procedure is more extensive than the original
Inappropriate use of Mod 58
when a patient is returned to the operating room for a complication.
Keyword:
return or
will proceed with additional services in next procedure etc.
Modifier 59
Distinct Procedural Service
Procedure or service distinct or independent from other non E/M services.
Modifier 59
*add to column 2 code if circumstances permit.
*modifier of last resort when no other is appropriate.
Used with code pairs listed in the NCCI
National Correct Coding Initiative
for a different
*session
*encounter
*procedure
*surgery
*site
*organ
*incision/excision
*lesion
Modifier 59 inappropriate uses
*Not listed in the NCCI
*Do NOT use w/ E/M codes
*Medicare: do NOT use w/ code pair that has a CCM (correct coding modifier) restricting the use of a modifier or if on eof the X-ESPU is appropriate.
*Documentation does not support services were separate and distinct.
*another modifier exists to describe service.
*Do NOT append w/ modifier 51 on the same procedure code.
X-[ESPU]
represents the separate
Encounter
Structure
Practitioner
Unusual service
Modifier 79 used for…
Unrelated procedure or service by the same Provider
*During Post-op
*Unrelated to the original procedure
*Performed during global period of first procedure.
*Do NOT use Mod 79 if second procedure is related to the first.
Modifier 80
*Used for Assistant Surgeon
*Provider assisted the surgeon
*MPFS relative files can be found on CMS website.
MPFS
Medicare Physician Fee Schedule
Review 5.4
What CPT® code is reported for an MRI of the brain without contrast?
Answer: B. 70551
Rationale: Look in the CPT® Index for Magnetic Resonance Imaging (MRI)/Diagnostic/Brain which directs you to 70551–70555. In the numeric section of CPT®, 70551 indicates without contrast.
Review 5.4
A provider orders a lipid panel. According to the practice standards, this includes a complete blood count (85027), total cholesterol (82465), HDL cholesterol (83718), and triglycerides (84478). What is reported on the claim form?
Answer: B. 80061, 85027
Rationale: The lipid panel by CPT® definition includes total cholesterol (82465), HDL cholesterol (83718), and triglycerides (84478). The CBC (85027) is reported separately, in addition to, the lipid panel (80061).
Review 5.4
Which reporting option below is correct for immunization administration for vaccines or toxoids?
Answer: A. 90460, 90474
Rationale: Read the parenthetical instructions in this section. Under 90474, there is a parenthetic instruction stating 90474 can be reported in conjunction with codes 90460, 90471, or 90473. 90461, 90472, and 90474 are all add-on codes and require a primary code be reported in addition.
Review 5.4
Which reporting option below is correct use of the modifier 50?
Answer: A. 19318-50
Rationale: There is guidance under the Integumentary System/Breast/Repair and/or Reconstruction heading that states to append modifier 50 when the procedures are performed bilaterally. 36251 is a unilateral procedure but there is an option for the same procedure to be performed bilaterally (36252). 36252 is a bilateral procedure and therefore should not have modifier 50 appended. 69801 has a parenthetic instruction stating not to report it more than once per day, using modifier 50 would equate to performing the procedure twice in one day.
Which reporting option below is correct use of a modifier with an E/M code?
Answer: B. 99213-25
Rationale: Modifiers 22, 54, 55, 56 and 59 are not appended to office visit codes. Modifier 25 indicates the office visit is separately identifiable from another procedure and is correct to append to an office visit code.
Global Package
The period (0–90 days as determined by the health plan) and services provided for a surgery inclusive of preoperative visits, intraoperative services, post-surgical complications not requiring a return trip to the operating room.
Global Surgery Status Indicator
An assigned indicator, which determines classification for a minor or major surgery, based on relative value unit (RVU) calculations.
Major Surgery
*Global surgical period includes day before, the day of, and follow-up 90 days after procedure.
Minor Surgery
*Global preop the day of surgery, surgery follow-up 0-10 days after.
NCCI
To promote correct coding.
To control improper assignment of codes.
To reduce inappropriate reimbursement.
National Correct Coding Initiative
*To determine codes
*Considered by CM to be bundled for major procedure.
