CPT code 6703679LT (for the vitrectomy) and CPT code 669845979LT (for the cataract removal). Unbundling is one of many issues that a medical billing expert might discover after a careful screening of medical bills. Note that CPT code books often include an abbreviated list of HCPCS Level II modifiers. Be sure to check code pairs each quarter (in January, April, July, and October). To assist with proper reporting and modifier placement, individual payers may provide lists that distinguish pricing modifiers from informational modifiers for their claims. Examples of Unbundling The CMS developed the Make sure you are not using ICD 10 combinations that are not allowed. All are subject to National Correct Coding Initiative (NCCI) edits. Upcoding is a sort of fraud in which healthcare practitioners submit incorrect billing codes to insurance companies in order to earn overpayments. Billing the steps individually allows the provider to recover more reimbursement for the same services. Q: If we order SCODI for glaucoma and OCT for retina on the same patient on the same day, are CPT codes 92133 and 32134 both billable? The same patient then has a left-eye cataract extraction (again, 66984) by the same physician during the global period for the first procedure. An informational modifier is a medical coding modifier not classified as a payment modifier. Medicares Global Surgery Booklet states that using modifier 58 signifies that performing a procedure or service during the postoperative period was one of the following (the CPT code book uses similar language): You should append modifier 58 to the code for the staged or related procedure. The Department of Justice said the hospital at Duke was applying a modifier to the codes so they could unbundle services that were typically billed together in this case, anesthesia in a cardiac procedure. Example 1: Separate Injury A patient undergoes pterygium surgery in the right eye. Unbundling can also be referred to as fragmentation.. If a hospital were to bill for the incision and stitches performed during a surgery as separate procedures, this would be an example of unbundling., Another example would be blood work. WebThe following are examples of healthcare fraud which you may encounter and should report: Misrepresentation of the type or level of service provided; Misrepresentation of the individual rendering service; Billing for items and services that have not been rendered; Billing for services that have not been properly documented; It could lead to unbundling, and such reporting falls under the purview of fraudulent medical billing. The code that appears in column 1 generally represents the major procedure or service. Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service, Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles, Separate structure, a service that is distinct because it was performed on a separate organ/structure, Separate encounter, a service that is distinct because it occurred during a separate encounter, Separate practitioner, a service that is distinct because it was performed by a different practitioner, Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service, Assistant surgeon (when qualified resident surgeon not available), Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery, Tech & Innovation in Healthcare eNewsletter, Unrelated postoperative evaluation and management (E/M) service, Separate E/M on same day as other service, Unplanned postoperative return to the operating room, Multiple same-date outpatient hospital E/M services, Separate encounter, practitioner, structure, service. Coding SOS. WebWhen unbundling is deemed appropriate, modifier 59 Distinct procedural service should be appended to the code in column 2. These are examples of some of the most commonly used CPT modifiers: Youll find CPT modifiers listed in your CPT code book. Modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period is appropriate for use only on E/M codes and only for services unrelated to the original procedure (the one with the global period). The MPFS lists fee maximums Medicare uses to pay physicians and other healthcare professionals on a fee-for-service basis. a written agreement, we do not represent you and have not agreed to do so. Immediate surgery is scheduled. We are a group of medical billing experts who offer comprehensive billing and coding services to doctors, physicians & hospitals. When a party needs to prove that a medical bill was reasonable to obtain reimbursement for the bill in litigation, unbundling can be evidence that the bill is excessive. A medical coding modifier is two characters (letters or numbers) appended to a CPT or HCPCS Level II code. hbspt.forms.create({ The CPT Surgery section guidelines are not as specific as the Medicare global rules regarding the operating/procedure room requirements. Unbundling is when you use different billing codes for components of a medical procedure when you are supposed to use a single comprehensive CPT code. The complaint also alleged that NextCare performed unnecessary medical procedures, such as redundant allergy testing. Medicaid billing is more complex than billing Medicare. Those codes are used in billings. So, you shouldnt report a separate E/M code for that work. While we will treat any information Unbundled charges will generally need to be bundled to produce a reasonable bill. A coder assigns Current Procedural Terminology (CPT) codes A modifier also may provide details not included in the code descriptor, such as the anatomic location of the procedure. She has over five years of experience in medical coding and Health Information Management practices. Section 1.2 and Section 60.1.1 both state, Coinsurance and deductible are waived for moderate sedation services (reported with G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service and when reported with modifier 33. To interpret the same physician requirement correctly, medical coders must remember that Medicare follows this rule found in Medicare Claims Processing Manual, Chapter 12, Section 30.6.5: Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. Only bill one E/M visit when the same provider meets the patient multiple times on the same day. A physician should not report CPT code 19301 (Mastectomy, partial ) plus CPT code 38745 (Axillary lymphadenectomy; complete). For example, imagine a patient receives a single medical service that includes a group of tests. CPT code 67810RT (for excising an eyelid lesion, except for a chalzion, without closure or with simple direct closure) and 6781059RT (for the biopsy). Medical billing coders review medical records, determine the service or procedure that the patient received, identify the CPT code that describes that service or procedure, and add the CPT code to the billing. The policy applies to work performed by same-specialty members of the same group. Appendix A of the AMA CPT code book explains that appending modifier 52 to a code is appropriate when provider discretion is the reason for partially reducing or eliminating a service or procedure. One payers list of pricing and informational modifiers may not match anothers list, so medical coders need to stay current on individual payer policy to avoid incorrect modifier placement that could affect claim processing. To avoid the medical coding mistake of unbundling, here is what you need to do: However, there can be exceptions to unbundling. Immediate surgery is scheduled. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. For unrelated procedures during the postoperative period, the CPT code set provides modifier 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period. If you are aware of upcoding, unbundling or other healthcare fraud and would like to discuss the matter with experienced and successful whistleblower attorneys and learn how a qui tam case would work, contact Phillips & Cohen for a free, confidential case review. ONE FREE PRESENTATION. If you have information about upcoding, unbundling, or other medical billing fraud, our medical billing attorneys are available for a free consultation regarding your options. Each code corresponds to a particular service or diagnosis and reflects the complexity of the work that the healthcare provider did. Access: Register in Hall A for $270. The goal of the NCCI is to prevent fraud and promote accurate coding. Pro-fee coders may consider appending modifier 52 Reduced services or modifier 53 Discontinued procedure to a medical code when a provider does not complete the full procedure or service described by that code. EndoGastric Solutions, Inc., a Washington-based medical device manufacturer, returned $5.25 million to the federal government to settle upcoding allegations. The choice to bundle or unbundle procedures affects the accuracy of medical bills. When a patient has a separate E/M service along with a procedure or other service on the same day by the same provider, you may report that E/M code separately for reimbursement by appending modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. This includes healthcare providers reimbursed through government healthcare programs like Medicare and Medicaid. Penalties under the FCA can be both civil and criminal, resulting in costly fines and even a prison sentence. These pages should not be construed to contain legal advice. As an obvious example, one CPT code describes the insertion of a needle into a vein. The Oct. 1 changes affected more than 320 CPT codes used in eye care. Individual payers may provide additional guidance. Copyright 2018 - 2020. For example, if the percentage of cases assigned to a particular DRG is usually 10 to 15 percent, but in your facility, 60 percent of cases are assigned to that DRG, your facility could become a target of a fraud investigation. Illegal unbundling would occur if a hospital performed the blood panel but fragmented and charges them as individual blood tests. The DRG and severity level are determined by diagnosis codes (ICD codes). NINE INSTRUCTION COURSES. Web7. You should not report an E/M code for that work, even with modifier 25 appended. WebAnswered by paguiajoy791. Here are some examples provided by the American Academy of Ophthalmology demonstrating how to unbundle NCCI edits: A patient has pterygium surgery in the right eye. Please call 888-720-8884. Print. A common use for modifier 78 is to report treatment for complications. When services should not be bundled, however, a medical practice will lose revenue when a coder bundles them in error. For instance, the WPS Government Health Administrators (WPS GHA) site includes a Pricing Modifier Fact Sheet that not only lists pricing modifiers, but also identifies which of those modifiers you should put in a secondary position if another pricing modifier is required for the code. Unbundling is billing for procedures separately that are normally covered by a single, comprehensive CPT code. If you dont append modifier 59, the insurance company would assume that the biopsy and excision involved the same lesion. 1 indicates that there are circumstances in which the edit can be unbundled. In this case, it is appropriate to append modifier -59 to unbundle since it was known preoperatively that the patient needed both procedures. When promoting its device, the pharmaceutical company advised providers to bill for the more expensive procedure, causing federal healthcare programs to pay more than needed. Payment for an AWV is limited to once per year. Oops, there was an error sending your message. You do not need to submit a copy of the ABN to Medicare, but you must have it available on request. He also ensures to submit accurate claims conveying the necessary information to the payer, preventing fraud risk and maximizing reimbursement. You and your staff work hard to deliver your patients the best possible medical care. Separate reporting of codes is justified for correct and complete reporting of the entire service. A patient undergoes pterygium surgery in the right eye. Use modifier GA when both covered and noncovered services appear on an ABN-related claim. TEPEZZA is a trademark owned by or licensed to Horizon. 2022 Horizon Therapeutics plc P-TEP-US-00805 12/22, By Sue Vicchrilli, COT, OCS, Academy Coding Executive, and Michael X. Repka, MD, MBA, Academy Medical Director for Governmental Affairs, Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Minority Ophthalmology Mentoring Campaign, Global Programs and Resources for National Societies, Dr. Richard Mills' Opinions, 2002 to 2016. for your patients with this serious, progressive disease. Two important categories are pricing modifiers (also called payment-impacting modifiers or reimbursement modifiers) and informational modifiers. In FY 2019, hospitals billed Medicare for hospital stays at the highest severity level for 40% of all 8.7 million Medicare inpatient cases. A code may depend on the length of time it took to perform the service (such as an office visit). The codes used by HCPCS were developed by the Centers for Medicare and Medicaid. WebExamples of Financial Abuse are: Billing for medical services that are unnecessary Upcoding and Unbundling Overcharging for supplies and services Common terms of Fraud and Abuse in the coding world are: Upcoding: Reporting a higher level of service than what is supported in the dictation Unbundling: There have been many successful whistleblower cases that have exposed fraud by healthcare providers that upcode treatment or services, or unbundle medical lab tests or groups of procedures. Improper coding also might occur through unbundling or fragmentation. Medicare and Medicaid often will have lower reimbursement rates for groups of procedures commonly performed together, such as incisions and closures incidental to surgeries. Bundling/Unbundling Medical Procedures. Each of the tests within a panel have individual and higher billing rates. The payer will apply the multiple-procedure fee reduction rules based on the codes reported and which of the nine possible MULT PROC indicators the fee schedule assigns to the code. In 2018, Prime Healthcare, a California hospital system, agreed to pay $65 million to the federal government in settlement of upcoding claims resulting in billing fraud. For some NCCI edits, CMS allows you to bill both codesin a process known as unbundlingif certain criteria are met. Unbundling is when you use different billing codes for components of a medical procedure when you are supposed to use a single comprehensive CPT code. That complexity becomes clear when procedures that have separate codes are performed together. Procedures that are performed together are termed bundled services, and each individual procedure is reimbursed at a lower rate because the government healthcare provider is paying for the procedure as a whole.