What to Do If a Patient Procedure Doesn't Fit Into Available Code Bundles

Code bundling can be helpful, but problems arise when a patient needs a service that isn't in the set of bundled codes. This can risk a provider not getting paid for extra services.

Sometimes, healthcare providers might avoid doing certain services or bill the patient more than they should to get full payment. This over-billing is called upcoding and is illegal.

"Bundling" is useful for payers to group similar services into one package. But sometimes, you need to bill for an extra service that doesn't fit into the bundle.

Here are the limited options:

1. Providers might leave out the extra service and lose money.

2. They might over-bill, which is illegal.

3. Billers might get a denial saying, "These procedures can't be billed together," which is a hassle.

So, what can be done?

National Correct Coding Initiative Edits:

Bundling and unbundling come from NCCI edits, specifically Procedure to Procedure (PTP) Edits. Unbundling can be done using specific modifier indicators. NCCI edits are released by CMS every year and are available on their website.

In NCCI edits, unbundling is allowed when codes have a "1" indicator (if requirements are met and reported with the right modifier). It is never allowed when codes have a "0" indicator.

Modifiers to Unbundle Procedures:

Modifiers are two-digit codes used in claims to give more information about the service performed.

Here are some common modifiers:

Modifier 25:

Used to unbundle E/M visits from other services done on the same day. This modifier is only for E/M services.

Modifier 24:

Allows you to separate services done during a global surgery period of 10 or 90 days.

Modifier 59 and its subsets:

Used to unbundle similar procedures done on the same day. Modifier 59 is often misused, so CMS made more specific subsets:

  • XE Separate Encounter, a service done at a different time.
  • XS Separate Structure, a service done on a different organ/structure.
  • XP Separate Practitioner, a service done by a different doctor.
  • XU Unusual Non-Overlapping Service, a service that doesn't overlap the main service.

Modifier 51:

Used on the second and later procedures done by the same doctor on the same day. It can also be used when medical procedures are done with surgical procedures.

Modifier 91:

Used to report repeated clinical lab tests done on the same day for the same patient. The repeated test must be medically needed.

Final Word

When billing similar or exclusive procedures, check the NCCI edits and modifier indicators. Knowing these modifiers helps get extra services reimbursed and avoid denials. Always have enough medical evidence before using these modifiers.

For more information you may contact any of our Medical Billing Experts.

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