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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. Examples featuring indicator 0. When promoting its device, EndoGastric advised providers to bill for the more expensive procedure, causing federal health care programs to pay more than needed. Unbundling or fragmenting billing codes illegally increases a providers profits by billing bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid. A: NCCI is updated quarterly. The MLN Fact Sheet Proper Use of Modifiers 59 & -X{EPSU} states you shouldnt report 29820 (with or without 59 or X{EPSU} modifiers) if you perform both procedures on the same shoulder during the same operative session. If a code has both a technical and a professional component and you report the code without using modifier 26 or TC, youre claiming that youve earned reimbursement for both components. 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. Medicare paid $7.4 billion to hospitals for those stays. Print. Unbundling can also be referred to as fragmentation.. Going beyond just getting the job done, we can help create sustainable improvement as part of your medical billing team. Medisys Data Solutions Inc. All rights reserved. The FCA protects and rewards whistleblowers who bring a claim against a provider or organization that is defrauding the government. It could lead to unbundling, and such reporting falls under the purview of fraudulent medical billing. When: From Sunday, Nov. 11, to Tuesday, Nov. 13. This means that when, for instance, you perform pterygium excision and cataract surgery together, youll get paid only for one of themif you submit codes for both, dont be surprised if you are reimbursed for the one with the lower allowable. The complaint also alleged that NextCare performed unnecessary medical procedures, such as redundant allergy testing. Prior results do not guarantee a similar outcome. ICD-10 and CPT code manuals are updated annually. Medical Coding Use of modifier. about a potential case to Phillips & Cohen LLP, we do not become your attorneys. Hospitals also can engage in upcoding lower-level charges for better-paying ones. Modifier 59 is needed to unbundle an NCCI edit. Fundamentals of Bundled Payments and Medical Billing. Unbundling coders are using multiple CPT codes for parts of a procedure, is one of the most common medical coding error identified by AMA in 2018. Whether procedures are performed separately or together might or might not determine the correct billing code. CMS identifies some edits as being mutually exclusive, which means they can never be paid separately. Immediate surgery is scheduled. Upcoding is when a healthcare service provider uses the billing code for a more expensive procedure when, in reality, a less expensive procedure was performed. In other words, if you removed all the documentation represented by the code for the other procedure or service, would the remaining documentation support reporting an E/M code? 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. Then report the discarded 5 units on another line with modifier JW appended to the supply code. Please call 888-720-8884. Modifier JW Drug amount discarded/not administered to any patient is not limited to use for Medicare claims. 1. Doctors, including primary care doctors as well as specialty doctors (such as psychiatrists, ophthalmologists, dermatologists, orthopedists, pain management doctors, wound care doctors and others), engage in upcoding when they use codes to reflect more expensive services than the ones they actually provided. Here is an example of when to use modifier 25 based on a scenario in Medicare Claims Processing Manual, Chapter 12, Section 40.1.C. By miscoding the patients visit, the physician has committed Medicare fraud because, among other things, the physician charged for services which were not provided. For instance, Medicare states you should use modifier JW only with drugs designated as single use or single dose on the FDA-approved label or package insert. ONE FREE PRESENTATION. Prime Healthcare allegedly directed its staff to upcode by exaggerating certain conditions. Similar codes may be available to describe the same service or procedure, depending on a number of factors. The rule that there is a 50 percent reduction on the second procedure does not pertain to testing services. Medisys Data Solutions Inc. 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. Durable medical equipment providers (DME) may engage in upcoding if they bill for more expensive equipment than actually provided. The question is one that coders must answer by relying on the rules that govern coding. Insurance Verification and Authorizations, Fragmenting one service into component parts and coding each component part as a separate service, Reporting separate codes for related services when one comprehensive code includes all related services, Breaking out bilateral procedures when one code is appropriate, Separating a surgical approach from a major surgical service. WebWhen a doctor bills for each service individually, even though Centers for Medicare and Medicaid Services (CMS) has assigned a code to the services as a group, he is unbundling. After checking allergy and immunization status, the physician performs the procedure. Unbundling means that two or more codes that are normally incidental to another can be billed separately. Youll use the surgery date as the date of service and can only use the modifier if the code has a global period of 10 days or 90 days. Refrain from billing integral procedures separately. She brings twenty five years of hands on management experience to the company. PracticeForces has served U.S. providers, solo medical practices, and multi-practice group owners since 2003. As every medical billing and coding company knows, it is important to distinguish when separate reporting of services is correct coding and when such reporting becomes fraudulent. Until we both sign Based on the descriptor, an E/M encounter must meet the criteria below to qualify for separate reporting using modifier 25. Studies of medical billing fraud make it clear that upcoding fraud and unbundling fraud dont happen in a vacuum. So, you shouldnt report a separate E/M code for that work. Repeated unbundling can be a red flag for fraud investigators. But, if the physician performs a medically necessary full neurological exam for the head trauma patient, then reporting a separate E/M with modifier 25 appended may be appropriate. a written agreement, we do not represent you and have not agreed to do so. Using the correct CPT code is therefore essential to obtaining the correct payment for services and procedures. CMS clarifies that not only are these practices unethical, but they can also expose providers to criminal and civil liability. Something that is unethical is not necessarily illegal, but it is in this context. assigning lower level CPT codes instead of reviewing patient record documentation & coding manual to determine the proper code. Billing patients with a medical condition with the same E/M code rather than choosing a medical code depending on the severity of the medical condition. Tips to Avoid Unbundling Codes 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. For example, if the closure of the surgical incision required an During the 90-day global period, the patient is hit in the left eye with a bungee cord, causing a traumatic cataract and vitreous hemorrhage. The rules for the reimbursement of multiple procedures mean payment for the code that is listed first will be 100 percent of its allowable; for the code listed second, 50 percent of its allowable. In 2014, Duke resolved a False Claims Act lawsuit alleging that it unbundled (and charged separately) for cardiac and anesthesia services that were performed together. If you perform the procedures on different shoulders, use modifiers RT and LT, not Modifiers 59 or -X{EPSU}.. You may append modifier 25 to an E/M code reported on the same date as a minor surgical procedure code, which is a code with global period indicator 000 or 010 on the Medicare Physician Fee Schedule (MPFS), according to Chapter I.E of the Medicare NCCI manual. Website Design by, Last updated Dec 2, 2022 | Published on Feb 26, 2019, Goiter occurs due to the irregular growth or overa, With us, get your verifications 3 to 5 days ahead, Root canal procedures treat infection at the soft, As one of the premier dental insurance verificatio, Outsourcing your medical billing to OSI can save y, An efficient patient eligibility verification proc, Advantages of Outsourcing Chiropractic Medical Billing, Learn the ICD-10 Codes to Identify Pneumonia. Individual modifiers may be appropriate only with certain codes, so be sure to check the rules specific to the case youre reporting. Claims that do not have the pricing modifier in the first position may encounter processing delays. Using code for a complex procedure when a routine medical service was performed. A: Only if one procedure was performed on the left eye and the other on the right. The goal of the NCCI is to prevent fraud and promote accurate coding. Get your Practice Analysis done free of cost. For example if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the provider should report CPT code 19302 (Mastectomy, partial, with axillary lymphadenectomy). CPT code 71046 Radiologic examination, chest; 2 views is an example of a code that has both professional and technical components.