Author Topic: Bundling?  (Read 6965 times)

blueskyportland

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Bundling?
« on: June 02, 2009, 02:29:34 PM »
Hi there! I just joined, and this is my first post, so forgive me if this topic has already been addressed, and please feel free to direct me to the thread in which it has been answered, if any.

I am a self-taught biller/office manager for an alternative healthcare clinic. I've had some tutorial, but have pretty much been learning as I go along. Recently I began billing for our naturopath, who has much more intricate superbills than our acupuncturists or massage therapists. As a result, I've begun to get claims rejected for reasons that seem simple enough, but that have not been explained to me. For instance -bundling and modifiers. I think I get the general concepts, but I don't have any good resources for modifier manuals or code books. We've been getting a lot of claims returned because the return visit codes and therapy codes "cannot be submitted 'unbundled'," however none of the claims departments are able to advise me as to how to bundle. I'm pretty much at a loss - any help you can offer would be greatly appreciated, from resources to specific advice.

As a specific example, for one date of service for a return patient i billed: 99213, 97140, and 96372. The 99213 code was not paid, but the injection 96372 code was - the explanation I received was, as mentioned above, that those two codes cannot be submitted unbundled.

Thanks so much!

PMRNC

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Re: Bundling?
« Reply #1 on: June 02, 2009, 07:07:07 PM »
You shouldn't be coding, the doctor should, especially since your not trained, you cannot learn simply by looking at the CPT Code book. The ultimate responsibility of coding falls on the doctor. If you are not qualified or trained, when he hands you the superbill you look it over and if it's not complete, give it back to him. Coding is done using the medical chart and is based on the elements of the E&M, ONLY he is in there with the patient and is responsible for documenting it, therefore responsible for assigning the proper codes and modifiers.
Linda Walker
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Michele

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Re: Bundling?
« Reply #2 on: June 02, 2009, 08:22:53 PM »
Linda is right, you shouldn't be coding.  The dr needs to let you know what was done.

However, If you are simply looking for the modifier that you need to use to have them process the charges separately you may want to try the 25 modifier on the E&M code (office visit).  If the dr is doing the ov and it is completely separate  (which only he can tell you) from the therapy he performed then you can bill the ov with the 25 modifier. 

If you've already done that and they are denying stating they do not allow the codes separately on the same visit there is not much you can do.  You could try to appeal by submitting office notes, etc. but it may not do any good.

Michele
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blueskyportland

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Re: Bundling?
« Reply #3 on: June 08, 2009, 06:23:44 PM »
thanks for the feedback! i don't do the coding, per se, but i am the only one in the office that does the billing and is very familiar with it, so i'm trying to help us all understand this bundling/modifier issue.
I recently looked up different modifiers that I feel we could use, including 25, 51, and 76. I'm going to try to resubmit the claims using these modifiers but, just so I'm sure about how to use them, could you verify that I just tack them on the end of the code? For example, when billing E/M code 99213 for a service date that also included a primary manual therapy code of 97140, with two subsequent 15 minute periods of administering the manual therapy, i would bill the line items as follows:

99213.25
97140
97140.76
97140.76

thanks again! i'm trying to convince the studio owner to buy some of your books! :)

Michele

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Re: Bundling?
« Reply #4 on: June 08, 2009, 08:42:38 PM »
The example you gave is not correct.  I would not use the 76 modifier on the 97140.  I would bill the 97140 with 3 units.

Michele
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blueskyportland

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Re: Bundling?
« Reply #5 on: June 09, 2009, 01:39:19 PM »
thanks Michelle! that's what i usually do, but like i said, i'm just now figuring out the bundling thing! so, adding the modifiers after the codes, separated by a decimal point is correct? thanks again!

Michele

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Re: Bundling?
« Reply #6 on: June 10, 2009, 06:55:09 AM »
We don't use a decimal point.  They are just in the separate fields on the cms form.

Michele
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Nmanju

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Re: Bundling?
« Reply #7 on: August 05, 2009, 11:15:44 AM »
I personally think that you can use modifier 76 as it is used when a physician repeats the same procedure.
So try billling

99213 25
97140 76 3 units (repetition of same procedure code thrice by the same physician)


Thanks,

Manju

Pay_My_Claims

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Re: Bundling?
« Reply #8 on: August 05, 2009, 01:37:24 PM »
You shouldn't be coding, the doctor should, especially since your not trained, you cannot learn simply by looking at the CPT Code book. The ultimate responsibility of coding falls on the doctor. If you are not qualified or trained, when he hands you the superbill you look it over and if it's not complete, give it back to him. Coding is done using the medical chart and is based on the elements of the E&M, ONLY he is in there with the patient and is responsible for documenting it, therefore responsible for assigning the proper codes and modifiers.

See, now we are saying it in unison!! Don't code, but be familiar so you will KNOW if something isn't right!!! Ahhhhhh agreement-land!!

Steve Verno CMBS, CEMCS

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Re: Bundling?
« Reply #9 on: August 08, 2009, 08:58:51 AM »
Unbundling has been a huge issue for many years.

Simply put, CMS, in conjunction with the AMA, looks at the CPT codes.  They determine which codes when performed at the same visit, cannot be billed together because the service that is bundled is also done when the other service is provided.  This is called the National Correct Coding Initiative or NCCI. 

Example:  You get a flat tire.  You change the tire and put on a spare.  To change a tire, you have to remove the lug nuts. take off the bad tire, put on the spare and replace the lug nuts.  The removal of the lug nuts is part of the tire changing process.  To unbundle, you bill for the lug nut removal. 

On a quarterly basis, CMS published new and updated bundling directives. 
http://www.cms.hhs.gov/NationalCorrectCodInitEd/
In addition to codes being included with each other. NCCI also tells you of services that are mutually exclusive with each other.  This simply means that the two services cannot be billed on the same date of service when performed at the same visit.  It means they can both be paid when provided independently on different dates of service.

With some services, The AMA and CPT reviews the NCCI.  Some new edits are added, some are removed.   Commercial insurance companies are not obligated to follow these bundling edits.  HIPAA has not mandated this, yet.  Commercial insurance companies can establish their own coding and bundling edits.  Providers who contract with an insurance company may have agreed to these coding and bundling edits due to contract languag which may have been ignored, misunderstood, or missed by the provider.  However, once the contract is signed by the provider then the terms of the contract are enforced by the insurance company.  This is why we need to know what a provider agreed to when contracted with an insurance company.   Providers who are not contracted may not be obligated to abide by an insurance company's internal coding policies.  The non-par provider may be able to fight back and win against the bundling denial, depending on how the appeal is written. 

NCCI has its own modifiers. Lets look at an example from CPT 97041:

Code 97140 is considered a Column 1 Code to:
64479 (1)  64480 (1)    
97124 (0)  97750 (1)  99186 (0)

When you have a column 1 and column 2 code, they mean the following:
The column 1/column 2 correct coding edit table contains two types of code pair edits. One type contains a column 2 (component) code which is an integral part of the column 1 (comprehensive) code. The other type contains code pairs that should not be reported together where one code is assigned as the column 1 code and the other code is assigned as the column 2 code. If two codes of a code pair edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 code is paid.
This means if you bill 64479 and 97140, 64479 will be paid and 97140 will be denied.

If you look 64479 has a modifier of (1). This means the following:  Modifier 1 indicates that a modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this specificity provides the basis upon which separate payment for the services billed may be considered justifiable. Generally, the modifiers which are most likely to add specificity, or further information to the billed codes, are: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, 58, 59, 78 and 79.  Some people like using modifier 59 bcause this modifier bypasses an insurance company's internal electronic denial edits.
Just because a modifier is allowed doesnt mean that it will be paid.  The unbundling must be clealy documented that it was medically necessarry to provide both servics at the same visit.  Even if documented as being medically necessary, this is no guarantee of payment by the insurance company. 

You can also see a modifier of (0).  This means Modifier 0 indicates that there are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.

Doctors do their own coding or they hire a trained, certified and experienced coder. But even when doing do, the provider is ultimately responsible for the coding performed and what was billed.  The provider or coding agent shoudl always review the NCCI to help prevent unbundling issues.

Unbundling is considered a risk area by the OIG.  It has been published as follows in the Code of Federal Regulations:  Billing companies that provide coding services should provide additional policies for risk areas that apply specifically to coding. (Federal Register / Vol. 63, No. 243 / Friday, December 18, 1998) and Unbundling (billing for each component of the service instead of billing or using an all-inclusive code) (Vol. 65, No. 194 / Thursday, October 5, 2000)  http://oig.hhs.gov/authorities/docs/physician.pdf

Last, how does this affect a patient?  I recently had a cardiac stress test. The cardiologist unbundled the stress test and billed my insurance company for the unbundled services.  The services were denied as being bundled per NCCI.  I am now being billed for these unbundled services.  The extra cost to me?  $750.00. I disputed this. The self taught coder/office manager stated, in writing, that they can use modifier 59 to unbundle. WRONG!  Modifiers are insurance codes, not codes to use to bill a patient.  The bill was denied for bundling.

So, boys and girls, that is the story of how two codes met, bundled, and lived happily ever after.





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Pay_My_Claims

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Re: Bundling?
« Reply #10 on: August 08, 2009, 05:45:42 PM »
LOL, only U

Steve Verno CMBS, CEMCS

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Re: Bundling?
« Reply #11 on: August 08, 2009, 08:06:10 PM »
I keep forgetting to tuck the cape in and put on the glasses.   ::)
I'l have a double chubby chuck, a mexicali chilibarb, and two cherry cokes
Left hand Blue, Right Leg Green
You got your peanut butter on my milk chocolate.
Dont cut the blue wire! 
I love spam.

Pay_My_Claims

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Re: Bundling?
« Reply #12 on: August 09, 2009, 09:03:13 AM »
Those that know U will still know you. You can't hide from us..:-)

MBP

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Re: Bundling?
« Reply #13 on: September 18, 2009, 02:36:49 PM »
Hi, i am very new at this forum and after my first 1 hour and 14 minutes i am already loving it!!!  :-* i have a comment towards blueskyportland mainly, because i am partially in the same situation. started working at the doctors office, started coding a bit (with supervision of course) and now i am doing the billing. i am loving it so far and i am thinking about starting my own living doing this, but i am still very confused and scared about only knowing the basics. i want to take a course (or read a book/books) to learn as much as i can and be good at this. what do you recommend? is it a doable dream to become a medical biller "from scratch" on my own? would you recommend any special reading, dos and donts.. anything.. i am buying at least a book or two from this website, but will that be enough? you scared me a little with your comments on blueskyportals coding experience, i feel like i am swimming in same waters, testing what goes and what doesnt, testing modifiers, procedure codes.. just because there is so many resources out there that it is really difficult to find one solid answer to a question. and there is sooo many questions now!! thank you!!

Steve Verno CMBS, CEMCS

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Re: Bundling?
« Reply #14 on: September 18, 2009, 04:17:26 PM »
Erika

please wait and gain some more experience.  YOu said something fantastic. It is difficult to find one solid answer.  How true.  This is because there are so many outside factors:

1)  Patient Benefits per patient
2)  Provider Contracts per doctor per insurance company
3)  State Laws (50) (HMO, COMMERCIAL,WORKERS COMP, AUTO, PATIENT BENEFITS, RECORDS)
4)  Federal Laws (COBRA, ERISA, HIPAA, TRICARE, SOCIAL SECURITY, FEDERAL EMPLOYEES)
5)  Provider Specialty
6)  Insured v Uninsured patient
7)  Type of patient (ADULT, CHILD, ELDERLY, PREGNANT)
8)  Type of Visit (Office, Emegency, Urgent, Inpatient, Surgery, Diagnostic)
9)  Medicaid, Medicare and appropriate HMOs
10)  Class Action lawsuits
11)  Patient lawsuits
12)  Claims adjudication or nonadjudication
13)  Billing Agent training, nontraining, and experience
14)  Use of Debt Collection Agency
15)  Provider Financial Plan
16)  Insurance Company Policies
17)  Coding rules and guidelines

I'l have a double chubby chuck, a mexicali chilibarb, and two cherry cokes
Left hand Blue, Right Leg Green
You got your peanut butter on my milk chocolate.
Dont cut the blue wire! 
I love spam.