Happy Friday!
Last Friday we discussed the principles around unbundling CPTs and how that can be inappropriate leading to denials and even legal action. This can occur either unknowingly or intentionally to increase revenue and is an important reminder to have a dedicated coder or knowledgeable billing reviewing your codes.
As a reminder, the Medicare National Correct Coding Initiative (NCCI) edits outline which services or procedures need to be bundled or cannot be billed separately. Please see last week’s post if you want more information.
This week we are going to talk about a few scenarios where it may be appropriate to unbundle.
Please consult your medical billers and coders regarding specific scenarios in your practice. These are examples only. As always if you need billing and coding services, please contact us today.
While normally procedures or services performed on the same day, same patient, and same provider are typically bundled, there are occasionally circumstances where it is okay to unbundle, use modifiers, and then capture revenue appropriately. If commonly billed procedures are performed separately for different incidents, then it may be appropriate to bill separately.
Example 1: If a patient comes into your office to have a nosebleed treated with a diagnostic nasal endoscopy (31231), you wouldn’t also code for the cautery (30903) and the endoscopy (31231), since managing the bleeding is part of the endoscopy procedure. However, if the patient comes back later in the day with continued bleeding and requires another procedure, then you are able to bill for the second treatment after using the 59 modifier. The 59 modifier is to signify a distinct procedural service.
Example 2: A patient has pterygium surgery in the right eye. 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. Immediate surgery is scheduled. Vitrectomy (67036) and cataract extraction (66984) are bundled. In this case, it is appropriate to append modifier -59 to unbundle since it was known preoperatively that the patient needed both procedures. Modifier -59 should be appended to CPT code 66984 because this is the second procedure submitted on the claim due to its lower allowable. Modifier 79 should be used to indicate that cataract removal and vitrectomy are unrelated to the pterygium surgery.
Example 3: For patients getting an exploration of a spinal fusion( CPT code 22830) describes an exploration of a spinal fusion. This can not be reported with another procedure of the spine in the same anatomic area. However, if the spinal fusion exploration is performed in a different anatomic area than another spinal procedure, CPT code 22830 may be reported separately with modifier 59 or XS.
The critical point is that there are key times when you may be able to unbundle a procedure or visit.
Two codes can sometimes be unbundled when the bundled code represents one of the following after proper documentation:
- a different session or patient encounter,
- a different procedure or surgery,
- a different site or organ system,
- a separate incision/excision,
- a separate lesion, or
- a separate injury or area of injury in extensive injuries.
In those cases, you must not forget to add appropriate modifiers to their CPT codes. You also want to have your billers pay close attention to the EOBs to make sure that the payer does not overlook the modifier thinking it was inappropriate. Even those billers that do review all EOBs closely may miss inappropriate bundling if they are not up to date on the latest NCCI edits.
If you or your team are struggling with coding, rejections or denials reach out today to National Revenue Consulting so we can help you get back on track.
Most healthcare professionals struggle to get the reimbursement they deserve from insurance companies so our company provides a dedicated team and a data-driven process so they increase revenue by up to 30%.
Contact National Revenue Consulting today for a no-obligation practice analysis to see if we could help support your practice and take the stress away from billing.
