Determining whether an E/M service occurred on the same date of service as another procedure or service is typically straightforward. These modifiers belong after pricing modifiers on the claim. So read through this blog to learn the two most common medical coding mistakes and our other suggestions. Medical Billing Fraud: Upcoding & Unbundling | Coding bundled Instead, they often occur alongside other illegal, unethical, or fraudulent billing practices. As an obvious example, one CPT code describes the insertion of a needle into a vein. A handful of HCPCS Level II codes are included in the list, as well. Unbundling is one of many issues that a medical billing expert might discover after a careful screening of medical bills. When: Saturday, Nov. 10, 8-11 a.m. Where: Room S105. Common Errors in Medical Billing and Coding, and Unbundling occurs when multiple CPT codes are used to report component parts of the procedure, either unintentionally or in order to increase payment. In 2017, nearly $3.4 billion of the $3.7 billion recovered by the government under the FCA was the result of cases reported by whistleblowers. CMS publishes a four-column tablethat it posts online and updates quarterly. The separate ICD-10-CM codes make the distinct reasons for the E/M and other procedure or service more obvious. For instance, an encounter may call for both CPT modifier 22 Increased procedural services and HCPCS Level II modifier LT Left side (used to identify procedures performed on the left side of the body) on one procedure code. Again, each surgeon reports the code with modifier 62 appended. Upcoding. Have Knowledge That a Provider Is Unbundling? Although both procedures require the same code, they are unrelated because each surgery was on a different eye. The goal of the NCCI is to prevent fraud and promote accurate coding. Thats because the guidelines for Medicaid billing depend on the state, so the claim submission formalities also, Keeping your facility in compliance with HIPAAs regulations is crucial for any Florida medical practice. 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). Natalie joined MOS Revenue Cycle Management Division in October 2011. to medical services and procedures. Under the False Claims Act, both the federal government and private citizens can prosecute and stop healthcare fraud. Billing the steps individually allows the provider to recover more reimbursement for the same services. Government healthcare programs reimburse more money for procedures that are performed separately. They will check National Correct Coding Initiative (NCCI) edits when reporting multiple codes. When medical billing services charge a patient separately for procedures that can be bundled in one, then it is Medisys Data Solutions RCM solutions ensures that the providers recover every $ they are entitled to. Got a Coding Conundrum? Loralee joined MOS Revenue Cycle Management Division in October 2021. Each NCCI edit identifies a pair of services or procedures that typically should not both be billed when performed by the same provider on the same patient on the same day. You and your staff work hard to deliver your patients the best possible medical care. Medicare still accepts modifier 59, but check with individual payers to see which modifiers they prefer for a distinct procedural service. Specialized Medical Billing & Coding Resources, Medicare Alignment for SIM Models through Customized Statewide Models. Delaware 19901, USA. And to make matters worse, medical coding mistakes expose your practice to penalties ranging from thousands to millions of dollars. 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. 9 indicates that a former edit has been deleted. Example 1: Separate Injury A patient undergoes pterygium surgery in the right eye. The ASST SURG (Assistant at Surgery) column provides information related to these modifiers: The ASST SURG indicator will let you know whether payment for the additional provider is permitted, not permitted, or possibly permitted if documentation supports medical necessity. Medicares Global Surgery Booklet provides these examples: The TEAM SURG (Team Surgery) column is connected to modifier 66 Surgical team. Whistleblowers may receive rewards of 15 percent to 30 percent of the amount the government recovers as a result of a qui tam lawsuit. All are subject to National Correct Coding Initiative (NCCI) edits. Making an incorrect choice is, in fact, one of the most common causes of billing errors. International Society of Refractive Surgery, Unrelated procedure or service by the same physician during the postoperative period. Unbundling Services by Manipulating Coding The two codes can be unbundled when the column 2 code represents one of the following: When unbundling, use modifier 59. Chapter 47: Medical Coding 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. A knowledgeable coder will identify and assign the appropriate CPT and/or HCPCS Level II code(s) to correspond to each component of the overall service provided, and submit accurate claims conveying the necessary information to the payer, preventing fraud risk and maximizing reimbursement. Individual modifiers may be appropriate only with certain codes, so be sure to check the rules specific to the case youre reporting. Reporting the same code for the initial procedure and the unrelated procedure may be appropriate, as this example of proper modifier 79 use shows: Suppose a patient has a right-eye cataract extraction reported using 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation. All Part B Medicare claims are processed in this way. Read these. Medicare also includes the decision to perform a minor surgical procedure in the procedure code, the NCCI manual states. As per AAPC, a clear understanding of the differences in the rules pertaining to coding, billing and reimbursement are necessary to know when unbundling can turn potentially difficult. Append modifier GA when you issue a mandatory ABN for a service as required, and the ABN is on file. When decision-making for the procedure or test is done on an office visit, dont bill another E/M when the patient comes back for the test/ procedure. CPT code 6703679LT (for the vitrectomy) and CPT code 669845979LT (for the cataract removal). Insurance companies and government agencies have agreed to pay a certain fee for each covered service or procedure identified by a CPT code. Each of the tests within a panel have individual and higher billing rates. Unbundling is billing for procedures separately that are normally covered by a single, comprehensive CPT code. When two procedures should be bundled in a single CPT code, coders who bill the two procedures separately using two CPT codes are unbundling the procedures. WebUnbundling in Medical Billing? by using some of the examples suggested by the Centers for Medicare & Medicaid Services (CMS). The code that appears in column 1 generally represents the major procedure or service. This type of code with a PC/TC split is called a global code (not to be confused with the global period and global surgical package). 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. Append modifier GY when Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit. For services like radiologic exams where the entity performing the test and the interpreting provider are often different, having separate professional and technical components simplifies reporting and payment. Payment would be 100 percent of the ALT and 100 percent of the gonioscopy. The False Claims Act gives employees and others who know about upcoding, unbundling and other healthcare fraud a way to report it safely. As per existing medical billing guidelines, you cannot fragment a service into parts and code each component separately. Use modifier GA when both covered and noncovered services appear on an ABN-related claim. Medical Coding Modifiers - CPT, NCCI & HCPCS Level II - AAPC Unbundling in medical billing is billing for procedures separately. 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. PracticeForces has served U.S. providers, solo medical practices, and multi-practice group owners since 2003. Medicare paid $7.4 billion to hospitals for those stays. Correct coding. For instance, a coder may use a modifier to indicate a service did not occur exactly as described by a CPT or HCPCS Level II code descriptor, but the circumstance did not change the code that applies. Upcoding occurs when a healthcare provider submits codes to Medicare, Medicaid or private insurers for more serious (and more expensive) diagnoses or procedures than the provider actually diagnosed or performed. 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. CMS identifies some edits as being mutually exclusive, which means they can never be paid separately. View them at www.aao.org/coding(click Coding Tools and then CCI Edits). Double billing also happens when providers bill for the same procedure first using an individual code and then as a bundled code. 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. CPT guidelines state that appending modifier 53 is appropriate when a patient is scheduled and prepared for a total colonoscopy, but the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances.. 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. NCCI, Part Two: Examples of Unbundling For instance, WPS Government Health Administrators has a Modifier 76 Fact Sheet that clarifies you should use the modifier for repeat procedures performed 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. According to the complaint, CareAll exaggerated the severity of its patients conditions in order both to increase billings and to bill for medically unnecessary services. Is CPT coding hard? Selecting the correct CPT code is vital to accurate billing. However, stitches are sometimes performed as a separate procedure, such as when a patient comes into the hospital with a pre-existing wound. To avoid the medical coding mistake of unbundling, here is what you need to do: However, there can be exceptions to unbundling. For codes that accept modifiers 26 and TC, the MPFS RVU spreadsheet provides RVUs and indicators specific to the global code and the individual components. Each NCCI edit signifies a pair of services or procedures that normally should not both be billed when performed by the same provider on the same patient on the same day. 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. An urgent care facility may Unbundling also occurs when a coder charges for two services when the code for the major service assumes that the minor service is also provided. Medical Billing Fraud: Upcoding & Unbundling, Gender Discrimination against Transgender and Nonbinary People, Wells Fargo Mortgage Modification Lawsuit. When a party needs to prove that a medical bill was reasonable to obtain reimbursement for the bill in litigation, unbundling can be evidence that the bill is excessive. Hospital inpatient costs are paid using pre-determined rates that vary according to the diagnosis-related group (DRG) assigned to the type of patient stay and the severity of the diagnosis. However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. 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. 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. Using a modifier to indicate that additional services were provided when the standard medical billing code covers those services. 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. 3 Major Medical Coding Mistakes That Providers Must Know Modifier 59 is needed to unbundle an NCCI edit. Modifier 76 Repeat procedure or service by same physician or other qualified health care professional is appropriate to use when the same provider repeats the procedure or service subsequent to the original procedure or service. For example, if the percentage of cases assigned to a particular DRG is usually 10 to 15 percent, but in your facility, 60 percent of cases are assigned to that DRG, your facility could become a target of a fraud investigation. 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. This includes healthcare providers reimbursed through government healthcare programs like Medicare and Medicaid. Here are some examples of unbundling from www.outpatientsurgery.net: Billing for a lesion excision and skin repair on a single service date would constitute unbundling and generate an NCCI edit. The choice to bundle or unbundle procedures affects the accuracy of medical bills. Another important global package modifier is modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period. Call 877-290-0440 or have a career counselor call you. A example of upcoding in healthcare could be a Medicare patient visits a doctor for an annual routine checkup, a service typically reimbursed by Medicare at $50. When: From Sunday, Nov. 11, to Tuesday, Nov. 13. These are examples of some of the most commonly used CPT modifiers: 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 26 Professional component 59 Distinct procedural service Similarly, the NCCI table shows that CPT code 65426 Pterygium excision with graft became bundled with CPT code 66984 Cataract extraction with IOL on July 1, 2001. Billing for more than the actual time spent with a patient. For each edit, see if unbundling is permitted by checking the numeric indicator in column 4. Those inpatient stays cost Medicare $54.6 billion that year. When promoting its device, EndoGastric advised providers to bill for the more expensive procedure, causing federal health care programs to pay more than needed. Procedures that are performed together are termed bundled services, and each individual procedure is reimbursed at a lower rate because the government healthcare provider is paying for the procedure as a whole. about a potential case to Phillips & Cohen LLP, we do not become your attorneys. HCPCS Level II modifiers are alphanumeric or have two letters. Keep in mind some ICD 10 codes must be accompanied by a code first or a second code. Unbundling or fragmenting billing codes illegally increases a providers profits by billing bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid.