example of unbundling in medical coding

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. Billing care at higher levels than the care provided results in significant overcharges to federal healthcare programs. Part of that includes ensuring there arent any billing errors causing damage to the bottom line. Master Bundling Basics - AAPC Knowledge Center 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. According to Acting Assistant Attorney General Chad Readler, because those who defraud the government often hide their misconduct from public view, whistleblowers are often essential to uncovering the truth. The False Claims Act (FCA) allows whistleblowers to bring cases alleging fraud on behalf of the government and entitles whistleblowers to between 15 and 25% of the money collected from a favorable verdict or settlement. Such relief may include: While the FCA offers rewards and protections for whistleblowers, its important for a whistleblower reporting medical billing fraud to consult an experienced attorney before taking action. A modifier also may provide details not included in the code descriptor, such as the anatomic location of the procedure. Appending both CPT and HCPCS Level II modifiers to a single code may be appropriate. Suppose the physician sees a patient with head trauma and decides the patient needs sutures. Whether intentional or unintentional, unbundling and upcoding can expose your medical practice to investigation and significant financial penalties. You and your staff work hard to deliver your patients the best possible medical care. Other factors that affect code selection include the complexity of a procedure and whether a service was provided in person or by telehealth. An intermediate/advanced workshop. Separate reporting of codes is justified for correct and complete reporting of the entire service. Immediate surgery is scheduled. This specificity gives auditors, payers, and providers more information to help them determine which type of reporting is prone to errors. History; physical examination; complexity of medical decision making; amount of time spent with the patient; nature of the patient's problem; need for coordination of care; need for counseling and/or teaching. PC is an abbreviation for professional component, but medical coders must take care not to accidentally append modifier PC Wrong surgery or other invasive procedure on patient in place of modifier 26. EndoGastrics device could be implanted through two procedures, one more invasive and more expensive than the other. To assist with proper reporting and modifier placement, individual payers may provide lists that distinguish pricing modifiers from informational modifiers for their claims. However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. Basics of Bundling and Unbundling in Medical Coding Americans spent over $3.5 trillion on healthcare in 2017, and fraudulent medical billing practices may account for as much as 3% of that spending, according to the National Healthcare Anti-Fraud Association. It does not include a patients room, a minor treatment room, a recovery room, or an intensive care unit (unless the patients condition was so critical there would be insufficient time for transportation to an OR)., As Medicare Administrative Contractor (MAC) Palmetto GBA explains in its modifier 78 page, If the subsequent surgery is related to the initial surgery but does not require a return to the operating room, and both are performed by the same surgeon, the subsequent surgery cannot be submitted separately. Medicares global surgical package is a policy that incorporates payment in the surgery code fee for necessary, routine services before, during, and after a procedure. Should they be billed as a single procedure or as two procedures? WebOutlier providers are those whose coding or billing practices are significantly outside the norm. 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. Improper medical billing is just one method of defrauding government healthcare programs. 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. In 2006, Tenet Healthcare Corporation resolved a whistleblower lawsuit alleging that, among other things, Tenet engaged in upcoding by assigning improper and unsupported diagnosis codes to Medicare and Medicaid in order to increase the reimbursement rate for Tenets hospitals. EndoGastric Solutions, Inc., a Washington-based medical device manufacturer, returned $5.25 million to the federal government to settle upcoding allegations. The modifier alerts the payer to process the claim as usual despite any gender-specific edits that may apply. In fact, the AAPC notes that, Separate reporting of bundled services is not impermissible unbundling when separate reporting was not intended to, and does not reasonably lead to, improper reimbursement. Examples featuring indicator 0. This article has already explained that global period indicators are relevant to modifier 25 and 57 use. 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. We represent clients nationwide with offices in Birmingham, AL, Tallahassee, FL and Albany, GA. Modifier 57 indicates that this is the exam to determine the need for surgery. 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. Government healthcare programs reimburse more money for procedures that are performed separately. WebWhen unbundling is deemed appropriate, modifier 59 Distinct procedural service should be appended to the code in column 2. The CPT guidelines state that complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported. Because rules may differ, medical coders should check individual payer policies on reporting complications treated during the global period. 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 consequences of overcoding prove serious. Medicare Claims Processing Manual, Chapter 17, Section 40, provides the example of a single-use vial labeled to contain 100 units that has 95 units administered and 5 units discarded. Only bill one E/M visit when the same provider meets the patient multiple times on the same day. In other words, the provider is charging for a higher level of a similar service than the one actually performed by the healthcare provider. Unbundling Services by Manipulating Coding Examples of Unbundling The CMS developed the You should not report an E/M code for that work, even with modifier 25 appended. While we will treat any information The service or procedure was provided to the patient more than once. What is Unbundling in Medical Billing? 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. Refer to the list of mutually exclusive medical procedures defined by the Centers for Medicare and Medicaid (CMS). He also ensures to submit accurate claims conveying the necessary information to the payer, preventing fraud risk and maximizing reimbursement. Medical Billing Errors - What Is Unbundling in healthcare? The MPFS splits the work required for a surgery into the PRE OP (Preoperative Percentage), INTRA OP (Intraoperative Percentage), and POST OP (Postoperative Percentage) columns, which show how much of the fee each portion of the surgical work earns in cases where the same provider is not responsible for every aspect of care. 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. Waiver of the deductible and coinsurance for ACP is limited to once per year. That code is used when the insertion is not part of another medical procedure. Those who file qui tam lawsuits are protected under the provisions of the False Claims Act that prohibit retaliation against whistleblowers, such as being discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment.. Each pair is known as an NCCI edit. Two important categories are pricing modifiers (also called payment-impacting modifiers or reimbursement modifiers) and informational modifiers. The use of electronic health records (EHR) software can facilitate upcoding and unbundling. 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. The FCA makes it illegal to submit a false claim for payment to the government by a government contractor. The legal issues surrounding whistleblower protections are complicated, and obtaining relief for discharge, demotion, or discrimination as a result of whistleblowing involves knowing how to navigate relevant federal and state laws. Medical billers work with (or share the duties of) medical coders. Although separate diagnoses are not required, experienced coders have found that linking one ICD-10-CM code to the procedure/service code and another ICD-10-CM code to the E/M code may speed claim processing. Medical Coding Modifiers - CPT, NCCI & HCPCS Level II - AAPC Seating will be limited. Examples featuring indicator 9. The MULT PROC (Multiple Procedure) column in the Medicare relative value files is connected to modifier 51 Multiple procedures. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code. WebFaculty AHIMA 2007 Audio Seminar Series ii Susan Von Kirchoff, MEd, RHIA, CCS, CCS-P Ms. Kirchoff has seen all sides of the healthcare environment from teacher, to coder, We $ecure., In the April 10, 2015 guidance, CMS Innovations presented a set of principles that CMS Innovations would consider in read more, Its quite common to receive a request for medical records from insurance carrier who is going to conduct an read more, It is interesting in this economy, with the so-called continued recession, that most of these practices; especially the administrators read more, The shift to value-based care has driven public What is Unbundling in Medical Billing? Test us for free with a no obligation free trial. The DRG and severity level are determined by diagnosis codes (ICD codes). It remains one of the most pervasive and troubling forms of CPT code 6703679LT (for the vitrectomy) and CPT code 669845979LT (for the cataract removal). Using separate codes for linked procedures when theres a single code for the whole group of procedures is known as unbundling. You enter the pricing modifier directly to the right of the procedure code on the claim. Medical billing fraud involves a wide range of illegal practices and can occur in many different settings. Keep up with medical billing and coding trends. Generally speaking, doctors make more when they unbundle services. For instance, you can bill twice for the same procedure within the 90 -days global period if the patient did not report the second issue when the first medical procedure was performed. She brings twenty five years of hands on management experience to the company. Using a modifier to indicate that additional services were provided when the standard medical billing code covers those services. Upcodingusing a code for a higher level of service 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. By clicking on Request a Call Back button, we assume that you are accepting our Terms and Conditions. The False Claims Act gives employees and others who know about upcoding, unbundling and other healthcare fraud a way to report it safely. So when is unbundling permissible? 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. The False Claims Act also protects healthcare whistleblowers from harassment, discrimination, or retaliation by their employers. NextCare Inc., an Arizona urgent care provider, paid $10 million to the federal government and several states, settling allegations that its employees inflated billings for a variety of urgent care procedures. to medical services and procedures. During the 90-day global period, she is hit in the left eye with a bungee cord, causing a traumatic cataract and vitreous hemorrhage. 2002 2023. 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. And to make matters worse, medical coding mistakes expose your practice to penalties ranging from thousands to millions of dollars. When providers upcode medical bills for Medicare and Medicaid patients, they cheat those healthcare programs of needed funds. Modifier 77 Repeat procedure by another physician or other qualified health care professional is appropriate to use when a different provider repeats a procedure or service subsequent to the original procedure or service. To do that, you apply the individual codes and a modifier All medical billing and coding companies should differentiate between when separate reporting of services is correct coding and when such reporting becomes fraudulent. a different session or patient encounter. The service or procedure has both professional and technical components. The policy applies to work performed by same-specialty members of the same group. Depending on payer rules, the number of modifiers required, and the space available, it may be appropriate to append modifier 99 Multiple modifiers to the code and then place additional modifiers in another section of the claim, such as CMS 1500 box 19. The MPFS relative value files also include columns to indicate Medicares code-specific policies on modifier use and payment when multiple providers perform a procedure at the same session. Where: Rooms S501-S504. The MPFS lists fee maximums Medicare uses to pay physicians and other healthcare professionals on a fee-for-service basis. Last month, EyeNet provided an overview of the National Correct Coding Initiative (NCCI), explaining that CMS lists pairs of services that should not be billed together when performed by the same provider on the same patient on the same day. Regarding diagnoses for these encounters, the Medicare and Medicaid NCCI manuals say the diagnosis can be the same for the procedure/service and separate E/M (both manuals include this in Chapter I.D). These pages should not be construed to contain legal advice. Those codes are used in billings. 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. A common type of upcoding is using an E&M code for a more complex and time intensive patient visit than was actually provided. Claim forms provide space for multiple modifiers. 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. Unbundling is the complete opposite of bundling. Coding Medicares Global Surgery Booklet supports this use of modifier 24, stating, Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery is not included in Medicares global surgical package. 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). Whistleblowers are entitled to financial reward between 15 and 25% of the total recovery. Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day, states Medicare Claims Processing Manual, Chapter 12, Section 40.7. All Part B Medicare claims are processed in this way. 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. You should report different diagnosis codes, however, only if the documentation and applicable coding guidelines support doing so. Below are some examples of HCPCS Level II modifiers: You can find HCPCS Level II modifier lists in HCPCS Level II code books and in online coding resources. Know which code to list first. A code may depend on the length of time it took to perform the service (such as an office visit). Access: Register in Hall A for $270. Modifiers also play an important role in reporting procedures and services performed during a surgical codes global period, which is the timeframe when the global surgical package concept applies. For the convenience of the patient, an Nd:YAG capsulotomy is performed on the left eye the same day as cataract surgery on the right eye. Modifier 59, referenced in the previous section, is just one of the modifiers that can bypass an NCCI edit. Our vision for the providers is You Cure. To return to our WPS GHA example, the payer lists modifier 59 as an informational modifier. Is there ever a circumstance in which it is appropriate to unbundle with modifier 59? Medicare (along with many other payers) splits some codes into professional and technical components. Unbundling can also be referred to as fragmentation.. The appropriate level of E&M (9921X57) or Eye code (9201X57). A coder assigns, Current Procedural Terminology (CPT) 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. Individual payers may provide additional guidance. 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. Maximizing Your Revenue with Our Medical Billing Services in Ohio, Outsourcing Mental Health Billing Services The Key to Improving Your Practice, Key Factors in Choosing Oncology Billing Company, General Requirements for Medicaid Providers in Florida. 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.

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