Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Call (404) 550-4615 Today To do error free coding, outsource medical billing to an expert and leading medical billing company. Is CPT coding hard? Insurance companies and government agencies have agreed to pay a certain fee for each covered service or procedure identified by a CPT code. Medical Billing Fraud: Upcoding & Unbundling Whistleblower 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. Determining whether an E/M service occurred on the same date of service as another procedure or service is typically straightforward. Example 1: Separate Injury A patient undergoes pterygium surgery in the right eye. 8 The Green STE A, Dover, You may use this modifier combined with modifier GX. 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.. 1. Upcoding occurs when providers report higher-level procedures or services than can actually be documented or by an unsupported medical diagnosis or Unbundling is a form of medical billing fraud that is similar to upcoding. The use of electronic health records (EHR) software can facilitate upcoding and unbundling. For example if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the provider should report CPT code 19302 (Mastectomy, partial, with axillary lymphadenectomy). Unbundling occurs when multiple CPT codes are used to report component parts of the procedure, either unintentionally or in order to increase payment. When a private citizen, or whistleblower, with information about healthcare fraud brings a successful qui tam lawsuit that results in a government recovery, they share in up to 30% of the money returned to federal healthcare programs. Although you would not receive payment for the Column 2 code of the edit without modifier 59 on one of the codes from the edit pair, you may find modifier 59 classified as an informational modifier rather than a payment modifier. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. Billing for more expensive durable medical equipment (DME) than provided. The two codes can be unbundled when the column 2 code represents one of the following: When unbundling, use modifier 59. Coding If two providers try to bill for services provided to the same patient for the same procedures on the same date, its called double billing. Medical billing experts We provide end to end billing and coding solutions. Generally speaking, doctors make more when they unbundle services. Test us for free with a no obligation free trial. The codes were developed and are maintained by the American Medical Association All are subject to National Correct Coding Initiative (NCCI) edits. The reason is that Medicare wants contractors to pay a consistent amount for those colonoscopy codes with modifier 53 appended. Copyright 2018 - 2020. Our goal is to turbocharge client practice revenues but to do it within the confines of CMS and HIPAA guidelines. 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. Providing Medical Necessity. 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. 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. Steps to Avoid Overcoding and Undercoding | Duke Health Billings to Medicare and Medicaid must use the HCPCS. WebCMS categorizes fraud and program integrity issues into 4 categories: (1) mistakes resulting in administrative errors, such as incorrect billing; (2) inefficiencies causing waste, such as ordering excessive diagnostic tests; (3) bending and abuse of rules, such as upcoding claims; and (4) intentional, deceptive fraud, such as billing for services What is Unbundling in Medical Billing? 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. In this case, it is appropriate to append modifier -59 to unbundle since it was known preoperatively that the patient needed both procedures. The Centers for Medicare & Medicaid Services (CMS) says that [m]isusing codes on a claim, such as upcoding or unbundling codes are unethical billing practices. When the third code exists, it is the correct code when the procedures are performed together. Given that fraudulent medical billing occurs on such a broad scale and is difficult to identify and prevent, taxpayers often bear the enormous burden of this fraud. Medicare paid $7.4 billion to hospitals for those stays. A upcoded bill can be sent to any payerwhether a private health insurer, Medicaid, Medicare, or the patient. In other words, although the two codes were formerly bundled together, that is no longer the case. A patient undergoes pterygium surgery in the right eye. Other factors that affect code selection include the complexity of a procedure and whether a service was provided in person or by telehealth. Upcoding is a sort of fraud in which healthcare practitioners submit incorrect billing codes to insurance companies in order to earn overpayments. Reliable medical billing and coding companies have a skilled team on board that can ensure that providers receive appropriate payment for the work they perform. 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. The first two columns list codes (including both CPT and HCPCS codes), the third lists an implementation date, and the fourth lists a single-digit number known as the indicator. Each time CMS identifies a new NCCI edit, a new line is inserted into the table. Check payer policy to confirm, but non-Medicare payers may follow Medicare rules. 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. Unbundling is a common coding error that results in higher reimbursement rates and revenues. Why Should You Hire A Medical Billing Company Right Before ThanksGiving? Using code for a complex procedure when a routine medical service was performed. For DMEPOS claims, modifier KX indicates the supplier ensured coverage criteria was met and that there is documentation to support medical necessity. Chapter 47: Medical Coding Modifier 33 Preventive services is referenced in Medicare Claims Processing Manual, Chapter 18. For example, overcoding might involve billing for a full 45-minute-long doctors visit when the patient met with a nurse for five minutes. A service or procedure was increased or reduced in comparison to what the code typically requires. Basics of Bundling and 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. The CO-SURG (Co-surgeons) column is related to modifier 62 Two surgeons. You should not use either modifier 76 or 77 on an E/M code, according to Appendix A of the AMA CPT code book. 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. Dont let complex medical billing and coding processes slow you down let us handle it for you! A: NCCI is updated quarterly. hbspt.forms.create({ WebHere are some examples provided by the American Academy of Ophthalmology demonstrating how to unbundle NCCI edits: A patient has pterygium surgery in the right Upcodingusing a code for a higher level of service Refrain from billing integral procedures separately. Correct coding for the exam. Inform your employer if any unethical behavior is being performed, either by a colleague, patient, or other physicians. When you know preoperatively that both procedures will be performed, it is appropriate to unbundle by appending modifier 59 to 66984. NCCI stands for National Correct Coding Initiative. 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). WebAnswered by paguiajoy791. Use of modifiers: It would not be enough to just append modifiers RT and LT. All Rights Reserved. Medical Coding You and your staff work hard to deliver your patients the best possible medical care. Coding Each code corresponds to a particular service or diagnosis and reflects the complexity of the work that the healthcare provider did. What Are Bundling and Unbundling in Medical Coding? An example of unbundling is billing parts of a single, whole procedure separately. ICD-10 and CPT code manuals are updated annually. assigning lower level CPT codes instead of reviewing patient record documentation & coding manual to determine the proper code. CPT coding guidelines say that simple repairs are included in the excision codes and should not be coded separately. Get your Practice Analysis done free of cost. The False Claims Act also protects healthcare whistleblowers from harassment, discrimination, or retaliation by their employers. Suppose the physician sees a patient with head trauma and decides the patient needs sutures. The list of CLIA-waived tests from CMS provides a long list of CPT lab codes that are appropriate to report with modifier QW. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code. Another name for informational modifiers is statistical modifiers. 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. This may prompt a wrong code to be used when billing and in turn, the patients insurance company may deny the claim, specifying lack of medical necessity.. International Society of Refractive Surgery. PracticeForces has served U.S. providers, solo medical practices, and multi-practice group owners since 2003. The indicator is 1, which means that it can be unbundled. Because the HCPCS Level II code set is not copyrighted, the modifiers are also publicly available on CMS HCPCS Quarterly Update site. When youre reporting an E/M code representing the decision to perform a major surgery (one with a 090 global indicator, which represents a 90-day global period), you should append modifier 57 Decision for surgery, and not modifier 25. 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 In other words, the two codes in an NCCI edit are bundled together. 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. In that case, you should report the 95-unit dose on one line. You should append modifier 79 to the code for the second procedure. When unbundling is a frequent billing error, the medical provider may have instructed the coder to unbundle as a way to increase revenue. This specificity gives auditors, payers, and providers more information to help them determine which type of reporting is prone to errors. Loralee joined MOS Revenue Cycle Management Division in October 2021. Outpatient hospitals and ambulatory surgery centers (ASCs) should use modifier 73 Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia and modifier 74 Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia for reporting. These are examples of some of the most commonly used CPT modifiers: Youll find CPT modifiers listed in your CPT code book. Learn what Eye M.D.s must do differently with ICD-10. NINE INSTRUCTION COURSES. Modifier 79 is used to indicate that these surgeries are unrelated to the pterygium surgery. Access: Free. Fundamentals of Bundled Payments and Medical Billing. However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. In addition to separating modifiers based on whether theyre from the CPT or HCPCS Level II code set, modifiers are also categorized by type. EndoGastric Solutions, Inc., a Washington-based medical device manufacturer, returned $5.25 million to the federal government to settle upcoding allegations. The documentation must clearly show that the provider performed extra E/M work beyond the usual work required for the other procedure or service on the same date. Use of modifier. You should report different diagnosis codes, however, only if the documentation and applicable coding guidelines support doing so. The two codes in a NCCI edits are bundled together when physicians paid of service or procedure that are normally not billed together when performed by the same physician on the same patient on the same day. During the 90-day global period, she is hit in the left eye with a bungee cord, causing a traumatic cataract and vitreous hemorrhage. Overcoding Undercoding And More Avoid These Top Medical Coding Mistakes 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. Improper medical billing is just one method of defrauding government healthcare programs. Selecting the correct CPT code is vital to accurate billing. 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. The MPFS includes a BILAT SURG (Bilateral Surgery) column that identifies how payment will differ if you report the code bilaterally. One lesion is excised and another is biopsied, both on the right lower lid. In addition to modifiers 26 and TC, the Medicare relative value files include modifier 53 Discontinued procedure. Billing patients with a medical condition with the same E/M code rather than choosing a medical code depending on the severity of the medical condition. Medical Upcoding In this case, it is appropriate to append modifier -59 to unbundle since it was known preoperatively that the patient needed both procedures. If you are aware of upcoding, unbundling or other healthcare fraud and would like to discuss the matter with experienced and successful whistleblower attorneys and learn how a qui tam case would work, contact Phillips & Cohen for a free, confidential case review.