example of unbundling in medical coding

3 Major Medical Coding Mistakes That Providers Must Know Example 1: Separate Injury A patient undergoes pterygium surgery in the right eye. Using a modifier to indicate that additional services were provided when the standard medical billing code covers those services. When unbundling is a frequent billing error, the medical provider may have instructed the coder to unbundle as a way to increase revenue. Ensure that your medical coding staff refers to the latest version of the National Correct Coding Initiative (NCCI) edits published by CMS. The attorneys at Price Armstrong have experience in successfully representing whistleblowers in FCA cases. A different anatomic site or organ system, A separate injury (or area of injury in the case of an extensive injury), Planned prospectively or at the time of the original procedure, More extensive than the original procedure, For therapy following a diagnostic surgical procedure, A procedure requires two physicians of different specialties to perform it. The CPT code should be used for the nasal endoscopy without adding a second CPT code that describes the cauterization of a nosebleed. The FCA also protects whistleblowers from the risk of employer retaliation. Unbundling is one of many issues that a medical billing expert might discover after a careful screening of medical bills. The FCA protects and rewards whistleblowers who bring a claim against a provider or organization that is defrauding the government. by Natalie Tornese | Last updated Dec 2, 2022 | Published on Feb 26, 2019 | Medical Billing | 0 comments. portalId: "5095596", Providers also might restrict the menus on their EHR software to show only diagnoses and treatment codes with the highest reimbursement rates. By clicking on Request a Call Back button, we assume that you are accepting our Terms and Conditions. You do not need to submit a copy of the ABN to Medicare, but you must have it available on request. When you know preoperatively that both procedures will be performed, it is appropriate to unbundle by appending modifier 59 to 66984. 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? Each code corresponds to a particular service or diagnosis and reflects the complexity of the work that the healthcare provider did. The question is one that coders must answer by relying on the rules that govern coding. If the government decides not to intervene in a qui tam case, whistleblowers and their counsel may then pursue the litigation on their own and recover funds on behalf of the government. 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. The False Claims Act gives employees and others who know about upcoding, unbundling and other healthcare fraud a way to report it safely. NCCI edits are used to review claims prior to payment. Use of modifier. Each surgeon bills the code with modifier 66 appended. 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. Most providers use the electronic equivalent of this form to bill Medicare for professional (pro-fee) services. Because the HCPCS Level II code set is not copyrighted, the modifiers are also publicly available on CMS HCPCS Quarterly Update site. The PCTC IND (PC/TC Indicator) column in the MPFS relative value files reveals whether a code has a PC/TC split and whether you may append modifiers 26 and TC to the code. 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). A: NCCI is updated quarterly. Meghann joined MOS Revenue Cycle Management Division in February of 2013. 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 For example, a provider might code a patient with acute bronchitis as being treated for chronic bronchitis, or code the excision of a small skin lesion as the excision of a larger, more complicated excisionthis often results in a cost difference and increased profit for the provider. assigning 0 ir 9 as the 4th or 5th digit instead of reviewing the coding manual for the appropriate code. 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. For a link to the CMS edits, go to www.aao.org/coding and click on Coding Tools, and then CCI Edits.. These examples prove yet again that proper use of medical coding modifiers is essential both for coding precision and for accurate payment. Master Bundling Basics - AAPC Knowledge Center

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