Unbundling is the topic for Friday’s Fraud Alert! Join us every Friday for tips on medical billing.
Unknowingly or knowingly, offices sometimes improperly unbundle CPT (current procedural terminology) codes to increase reimbursement or due to misunderstanding. Unbundling occurs when an office will bill multiple CPT codes for services that should be covered by a single CPT code.
Every year, the Centers for Medicare and Medicaid (CMS) publishes National Correct Coding Initiative (NCCI) edits that outline codes that should not be billed together. Every medical billing team should use this as a guide to help bill for services appropriately.
What is the National Correct Coding Initiative (NCCI) (Reference CMS.gov)?
The Medicare National Correct Coding Initiative (NCCI) supports national correct coding methodologies and controls improper coding leading to inappropriate payment.
The goal of the NCCI is to prevent improper coding and fraudulent claims.NCCI edits outline which services or procedures normally should not be billed by the same provider on the same patient on the same day.
Essentially, if two codes are outlined as bundled together in the NCCI edits that means that cannot be unbundled and reported as separate CPTs (unless specific conditions are met). Even if this is done unintentionally it can lead to charges for fraud and can even lead to expensive fines.
Fraud Case Example (Reference Wallace Law):
In March 2014, Duke University settled a False Claims Act case with the U.S. Department of Justice (DOJ), agreeing to pay $1,000,000 to resolve accusations it had defrauded the government’s healthcare programs. Duke was accused of unbundling cardiac and anesthesia services. DOJ said that the North Carolina hospital was adding a modifier “59” to the codes it used in order to unbundle services that really should have been billed together.
A healthcare provider is only supposed to use the 59 modifier in unusual situations where it is essentially treating a patient twice on the same day, for example, when the patient has injuries to two different parts of the body. The CPT manual says, “Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”
In this case, however, DOJ said that Duke was adding the 59 modifier in order to hide the fact that it was unbundling. The Government recovered the money thanks to a whistleblower who brought the FCA case. The whistleblower had been a billing coder and auditor at Duke.
Examples of unbundling:
- Billing for the introduction of a needle or intracatheter into a vein (CPT code 36000), venipuncture (CPT code 36410), drug administration (CPT codes 96360-96377), or cardiac assessment (e.g., CPT codes 93000-93010, 93040-93042) shall not be reported when these procedures are related to the delivery of an anesthetic agent.
- Reporting integral services that do not have specific HCPCS/CPT® codes for reporting the service.
- Reporting multiple HCPCS/CPT® codes when a single comprehensive code describes these services. For example, if a provider performs a vaginal hysterectomy on a uterus weighing less than 250 grams with bilateral salpingo-oophorectomy, the provider shall report CPT® code 58
- New as of 1/1/2022 (III-5) If it is necessary to incise and/or drain a lesion as part of another procedure or in order to gain access to an area for another procedure, the incision and/or drainage is not separately reportable if performed at the same patient encounter. For example, a physician excising pilonidal cysts and/or sinuses (CPT codes 11770-11772) may incise and drain one or more of the cysts. It is inappropriate to report CPT codes 10080 or 10081 separately for the incision and drainage of the pilonidal cyst(s).
- Fragmenting a procedure into its component parts and coding each component as if it were a separate procedure.
- Unbundling a bilateral procedure code into two unilateral procedure codes. For example, if a provider performs bilateral mammography, the provider shall report CPT® code 77066 (Diagnostic mammography… bilateral). The provider shall not report CPT® code 77065 (Diagnostic mammography… unilateral) with two units of service or 77065LT plus 77065RT.
- Unbundling services that are integral to a more comprehensive procedure. o For example, surgical access is integral to a surgical procedure. A provider shall not report CPT® code 49000 (Exploratory laparotomy,…) when performing an open abdominal procedure such as a total abdominal colectomy (For example, CPT® code 44150).
It is really important to avoid fragmenting one service into component parts and coding each component part as a separate service or reporting separate codes for related services when one comprehensive code exists to include all related services.
See next week’s Friday Fraud Alert for when unbundling can occur!
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