Four colonoscopy codes (44388, 45378, G0105, and G0121) have one row for the code and one row for the code with modifier 53. Unbundled charges will generally need to be bundled to produce a reasonable bill. The appropriate level of E&M (9921X57) or Eye code (9201X57). Because the list changes regularly, you should search online for updates. Explore TEPEZZA (teprotumumab-trbw) nowfor your patients with this serious, progressive disease. You should append modifier 53 when the provider terminates a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the well being of the patient, Appendix A states. Upcoding and Unbundling Charges in Medical Billing Medical Billing Claims that do not have the pricing modifier in the first position may encounter processing delays. 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. Penalties under the FCA can be both civil and criminal, resulting in costly fines and even a prison sentence. CMS publishes pairs of codes, known as NCCI edits, that should not be billed together. Billing the steps individually allows the provider to recover more reimbursement for the same services. Unbundling Services by Manipulating Coding 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. The NCCI table shows that CPT code 92020 Gonioscopy became bundled with CPT code 65855 Argon laser trabeculoplasty or selective laser trabeculoplasty on Jan. 1, 1996, with an indicator of 1. The policy applies to work performed by same-specialty members of the same group. Attorney Advertising. These are examples of some of the most commonly used CPT modifiers: Youll find CPT modifiers listed in your CPT code book. When providers upcode medical bills for Medicare and Medicaid patients, they cheat those healthcare programs of needed funds. Healthcare Fraud and Abuse Government healthcare programs reimburse more money for procedures that are performed separately. However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. Another example is use of the exploratory laparotomy Illegal unbundling would occur if a hospital performed the blood panel but fragmented and charges them as individual blood tests. This article has already explained that global period indicators are relevant to modifier 25 and 57 use. Use of modifiers: It would not be enough to just append modifiers RT and LT. Like many healthcare careers, becoming a medical biller and coder will take education and training. A service or procedure was increased or reduced in comparison to what the code typically requires. In this case, it is appropriate to append modifier -59 to unbundle since it was known preoperatively that the patient needed both procedures. Bundling rules typically require a healthcare provider to use the code for the more significant procedure when a minor procedure is performed at the same time. Medisys Data Solutions Inc. All rights reserved. For example, if the patient pays an office visit and the surgery is on the same day, the coder may unbundle it. Pairs of codes should not be billed together. The MPFS lists fee maximums Medicare uses to pay physicians and other healthcare professionals on a fee-for-service basis. Understanding Unbundling or Fragmenting Medical Billing Codes A patient comes for a set of 3 trigger point injections as per the plan, the physician cant bill these injections for an office visit unless the patient presents another problem. To assist with proper reporting and modifier placement, individual payers may provide lists that distinguish pricing modifiers from informational modifiers for their claims. When services should not be bundled, however, a medical practice will lose revenue when a coder bundles them in error. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Coding fraud, along with pharmaceutical fraud, illegal physician kickbacks, and pharmacy fraud, cost the federal government and taxpayers billions of dollars a year and raise the cost of healthcare services. A: NCCI is updated quarterly. Loralee joined MOS Revenue Cycle Management Division in October 2021. Unbundling Fraud: Case Examples | Whistleblower Lawyer Atlanta Before appending modifier GV to a code, you should check these points: Medicare Claims Processing Manual, Chapter 11, Section 40.1.3, provides more information about attending physicians for hospice patients. ABN claim reporting modifiers are listed in the MLN booklet Medicare Advance Written Notices of Noncoverage with the following explanations: Modifier GA Waiver of liability statement issued as required by payer policy, individual case, Modifier GX Notice of liability issued, voluntary under payer policy, Modifier GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit, Modifier GZ Item or service expected to be denied as not reasonable and necessary. A example of upcoding in healthcare could be a Medicare patient visits a doctor for an annual routine checkup, a service typically reimbursed by Medicare at $50. hbspt.forms.create({ One type of upcoding occurs when hospitals bill for inpatient stays at the highest severity level even though the patients care was actually more routine. Selecting the correct CPT code is vital to accurate billing. Some payer programs may have modifiers that apply only when youre reporting codes in connection with those programs, as well. Elements such as payer policy and setting will determine whether you use modifier 95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system or modifier GT Via interactive audio and video telecommunication systems. The OIG said the billing patterns suggest possible upcoding in many cases, particularly since almost 30% of the inpatient stays at the hospitals lasted a particularly short time. But keep in mind some points related to Medicares global surgery rules. Explore TEPEZZA (teprotumumab-trbw) nowfor your patients with this serious, progressive disease. In some cases, there are three CPT codes to consider: two that describe each of two separate procedures and a third that describes the two procedures when they are performed together. A handful of HCPCS Level II codes are included in the list, as well. 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. Explain the following coding errors and provide an example. Call 877-524-5027 to speak to a representative. Consequently, for those payers that do not accept modifier 51, the MULT PROC column offers information about expected payment rather than about whether to use modifier 51. formId: "5d6af30a-df47-4431-b9ca-2e5dfd34d5d3" 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. 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. The CPT code should be used for the nasal endoscopy without adding a second CPT code that describes the cauterization of a nosebleed. Tenet Healthcare Corporation. Pharmaceutical companies and medical device manufacturers may also commit healthcare fraud by upcoding. We provide end to end billing and coding solutions. It is expected that a doctor will cauterize a nosebleed if the nosebleed is occurring during a nasal endoscopy. A: Only if one procedure was performed on the left eye and the other on the right. When a private citizen, or whistleblower, with information about healthcare fraud brings a successful qui tam lawsuit that results in a government recovery, they share in up to 30% of the money returned to federal healthcare programs. When the third code exists, it is the correct code when the procedures are performed together. If you are aware of any illegal medical billing practices, contact a medical billing fraud attorney today for a confidential, free consultation. Most errors can be avoided if the medical coder or biller takes a few simple steps: Stay current and on top of code changes. CPT modifiers are generally two digits, although performance measure modifiers that apply only to CPT Category II codes are alphanumeric (1P-8P). If the provider bills for each test separately rather than billing for the It could lead to unbundling, and such reporting falls under the purview of fraudulent medical billing. Suppose, for example, that a biopsy reveals a malignant tumor. Medisys Data Solutions Inc. As per AAPC, a clear understanding of the differences in the rules pertaining to coding, billing and reimbursement are necessary to know when unbundling can turn potentially difficult. For example, the CPT code for surgery to raise or elevate a depressed bone in a simple skull fracture is different from the code used to describe surgery that elevates a compound skull fracture. Although you would not receive payment for the Column 2 code of the edit without modifier 59 on one of the codes from the edit pair, you may find modifier 59 classified as an informational modifier rather than a payment modifier. That code is used when the insertion is not part of another medical procedure. The indicator is 1, which means that it can be unbundled. That complexity becomes clear when procedures that have separate codes are performed together. 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. That can be a difficult task, as the AMA has created thousands of CPT codes. Medical Billing Fraud: Upcoding & Unbundling, Gender Discrimination against Transgender and Nonbinary People, Wells Fargo Mortgage Modification Lawsuit. WebCMS categorizes fraud and program integrity issues into 4 categories: (1) mistakes resulting in administrative errors, such as incorrect billing; (2) inefficiencies causing waste, such as ordering excessive diagnostic tests; (3) bending and abuse of rules, such as upcoding claims; and (4) intentional, deceptive fraud, such as billing for services As an obvious example, one CPT code describes the insertion of a needle into a vein. The CPT code book Introduction provides these additional examples of when a modifier may be appropriate: Proper use of modifiers is important both for accurate coding and because some modifiers affect reimbursement for the provider. coding Health Care Fraud and Abuse Insurance companies and government agencies have agreed to pay a certain fee for each covered service or procedure identified by a CPT code. Appending both CPT and HCPCS Level II modifiers to a single code may be appropriate. Modifier 33 Preventive services is referenced in Medicare Claims Processing Manual, Chapter 18. The goal of the NCCI is to prevent improper coding and fraudulent claims. The question is one that coders must answer by relying on the rules that govern coding. International Society of Refractive Surgery. In other words, the provider is charging for a higher level of a similar service than the one actually performed by the healthcare provider. Automated claims processing systems can use the table of NCCI edits to review claims for irregularities. Use of modifiers. Each pair is known as an NCCI edit. In 2018, the American Medical Association (AMA) identified unbundling codes or using multiple CPT codes for parts of a procedure, as one of the most common medical coding errors. Bring your queries to the Coding Desk at the Academy Resource Center (Booth 508), where you can chat with AAOE experts and browse the AAOEs coding resources, such as the Ophthalmic Coding Series and Ophthalmic Coding Coach. Government and private insurers use these codes to determine how much to pay for the services and procedures. 1. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules. A careful comparison can uncover unbundling errors that result in inflated billing. Table 1 shows the complete listing of NCCI PTP-associated modifiers. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. If you perform the procedures on different shoulders, use modifiers RT and LT, not Modifiers 59 or -X{EPSU}.. As per existing medical billing guidelines, you cannot fragment a service into parts and code each component separately. Note: Medicare and many other payers implemented temporary rules related to reporting telehealth codes, modifiers, and POS during the Public Health Emergency (PHE) related to COVID-19, so be sure to follow the guidance that applies to your service. These are examples of some of the most commonly used CPT modifiers: 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 26 Professional component 59 Distinct procedural service The manual also states you may append modifier 25 to an E/M code performed on the same date as a code with a global indicator of XXX. Providing Medical Necessity. The CPT definition of modifier 59 advises that the modifier may be appropriate for a code when documentation shows at least one of the following: The CPT definition also states that you should not use modifier 59 when a more descriptive modifier is available. The DRG and severity level are determined by diagnosis codes (ICD codes). Again, each surgeon reports the code with modifier 62 appended. 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; 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. With 10 distinct indicators, medical coders benefit from referring to a current list of MPFS modifier indicator definitions to ensure theyre using the modifiers correctly. Immediate surgery is scheduled. NCCI, Part One: When Can You Unbundle? Medical Coding Errors Bundling refers to the use of a single CPT code to describe two separate procedures that were performed at the same time. Here are some examples of unbundling from www.outpatientsurgery.net: Fragmenting one service into component parts and coding each component part as a A high severity level requires that there be at least one secondary diagnosis that is considered a major complication or comorbidity, such as acute respiratory failure and sepsis. The United States Attorney General has estimated that Medicare fraud amounted to between $60 and $90 billion per year, with similar levels of fraud affecting Medicare. ICD-10 and CPT code manuals are updated annually. If a whistleblower faces demotion, harassment or discrimination for bringing attention to medical billing fraud, they are entitled to all relief necessary. The Multi-Carrier System (MCS) that Medicare uses for claims processing requires pricing modifiers to be in the first modifier position, before any informational modifiers. Last Reviewed on Aug. 19, 2022, by AAPC Thought Leadership Team, 2023 AAPC |About | Privacy Policy | Terms & Conditions | Careers | Advertise with Us | Contact Us. One lesion is excised and another is biopsied, both on the right lower lid. Duke settled the lawsuit for $1 million. Example 1: Separate Injury A patient undergoes pterygium surgery in the right eye. In that case, you should report the 95-unit dose on one line. The Centers for Medicare & Medicaid Services (CMS) says that [m]isusing codes on a claim, such as upcoding or unbundling codes are unethical billing practices. By clicking on Request a Call Back button, we assume that you are accepting our Terms and Conditions. What Are Bundling and Unbundling in Medical Coding? Contact Us for a Free, Confidential Consultation. WebHere are three more examples demonstrating how to unbundle NCCI edits. A knowledgeable coder will identify and assign the appropriate CPT and/or HCPCS Level II code(s) to correspond to each component of the overall service provided, and submit accurate claims conveying the necessary information to the payer, preventing fraud risk and maximizing reimbursement. Using code for a complex procedure when a routine medical service was performed. Correct coding for the exam. Unbundling also occurs when a coder charges for two services when the code for the major service assumes that the minor service is also provided.
example of unbundling in medical coding