Coding > Coding
Bundling?
blueskyportland:
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:
We don't use a decimal point. They are just in the separate fields on the cms form.
Michele
Nmanju:
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:
--- Quote from: PMRNC on June 02, 2009, 10:07:07 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.
--- End quote ---
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:
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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