Modifiers 73 and 74 apply only when the procedure is discontinued due to extenuating circumstances or issues that threaten the wellbeing of the patient. Medical billing and coding can be hard at times, but it is by no means impossible. It remains one of the most pervasive and troubling forms of Our goal is to turbocharge client practice revenues but to do it within the confines of CMS and HIPAA guidelines. However, staying within the regulations is often easier said than, Subscribe for actionable tips and insights to grow your medical practice >. 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 Illegal unbundling would occur if a hospital performed the blood panel but fragmented and charges them as individual blood tests. Below are additional modifiers NCCI identifies as Global Surgery Modifiers, which means the modifiers may allow you to identify that a service is separately payable even though it occurred during a surgerys global period. Individual modifiers may be appropriate only with certain codes, so be sure to check the rules specific to the case youre reporting. The manual also states you may append modifier 25 to an E/M code performed on the same date as a code with a global indicator of XXX. Such relief may include: While the FCA offers rewards and protections for whistleblowers, its important for a whistleblower reporting medical billing fraud to consult an experienced attorney before taking action. Duke paid $1,000,000 after it was accused of unbundling cardiac and anesthesia services. Modifier 59, referenced in the previous section, is just one of the modifiers that can bypass an NCCI edit. So, you shouldnt report a separate E/M code for that work. The doctor, however, codes the visit as a more expansive checkup, which is reimbursed by Medicare at $100. A careful comparison can uncover unbundling errors that result in inflated billing. Medical billing and coding errors lead to the loss of revenue, claims denial, fines, and federal penalties. That code is used when the insertion is not part of another medical procedure. Examples featuring indicator 1. Some payer programs may have modifiers that apply only when youre reporting codes in connection with those programs, as well. coding Vitrectomy (67036) and cataract extraction (66984) are bundled. Unbundling is the opposite of bundling. This modifier is appropriate when more than two surgeons of different specialties perform a procedure. Immediate surgery is scheduled. The MLN Fact Sheet Proper Use of Modifiers 59 & -X{EPSU} states you shouldnt report 29820 (with or without 59 or X{EPSU} modifiers) if you perform both procedures on the same shoulder during the same operative session. Examples featuring indicator 0. If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance will be applied to the ACP.. Append modifier GX when you issue a voluntary ABN for a service Medicare never covers because the service is statutorily excluded or is not a Medicare benefit. As an example, modifier QW CLIA waived test is a HCPCS Level II modifier that alerts the payer that the test being reported has waived status under the Clinical Laboratory Improvement Amendments (CLIA). The corresponding code in column 2 may represent a component of the column 1 code. A skilled 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. The global fee for the initial surgery includes additional related surgical procedures that do not require a return to the operating room.. Unbundling means that two or more codes that are normally incidental to another can be billed separately. Unbundling or fragmenting billing codes illegally increases a providers profits by billing bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid. We represent clients nationwide with offices in Birmingham, AL, Tallahassee, FL and Albany, GA. To alert the payer that different providers are involved, CPT provides these modifiers: Review payer rules for proper use of these modifiers. 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. An example of unbundling is billing parts of a single, whole procedure separately. When you know preoperatively that both procedures will be performed, it is appropriate to unbundle by appending modifier 59 to 66984. Test us for free with a no obligation free trial. Medicare (along with many other payers) splits some codes into professional and technical components. Generally, upcoding and unbundling are difficult to detect without the help of whistleblower insiders. Bills can also include line items for texts, medicine or visits that were never provided. The OIG said the billing patterns suggest possible upcoding in many cases, particularly since almost 30% of the inpatient stays at the hospitals lasted a particularly short time. The two codes in an NCCI edit are bundled together. The two codes can be unbundled when the column 2 code represents one of the following: When unbundling, use modifier 59. For example, the CPT code for surgery to raise or elevate a depressed bone in a simple skull fracture is different from the code used to describe surgery that elevates a compound skull fracture. Claims that do not have the pricing modifier in the first position may encounter processing delays. A modifier also may provide details not included in the code descriptor, such as the anatomic location of the procedure. If whistleblowers are not backed by attorneys who know the law, and who know how to handle FCA cases, they can face severe personal and professional harm. ABN claim reporting modifiers are listed in the MLN booklet Medicare Advance Written Notices of Noncoverage with the following explanations: Modifier GA Waiver of liability statement issued as required by payer policy, individual case, Modifier GX Notice of liability issued, voluntary under payer policy, Modifier GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit, Modifier GZ Item or service expected to be denied as not reasonable and necessary. responsibility for care read more, With Thanksgiving around the corner, its that time of year when we genuinely think about giving thanks for all read more. What do these three pairs of procedures have in common: pterygium excision and cataract surgery; visual fields and blepharoplasty; and gonioscopy and argon/selective laser trabeculoplasty (ALT/SLT)? Unbundling is when you use different billing codes for components of a medical procedure when you are supposed to use a single comprehensive CPT code. If you have information about medical billing fraud, contact the attorneys at Price Armstrong. The final group of modifiers covered here relate to the MPFS, which is funded by Medicare Part B. Medicare includes some add-on codes in NCCI PTP edit pairs. Use of modifiers: It would not be enough to just append modifiers RT and LT. CMS publishes NCCI edits as a table of codes. a separate injury or area of injury in extensive injuries. assigning 0 ir 9 as the 4th or 5th digit instead of reviewing the coding manual for the appropriate code. 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. Our goal is to turbocharge client practice revenues but to do it within the confines of CMS and HIPAA guidelines. Unbundling Fraud: Case Examples | Whistleblower Lawyer Atlanta assigning lower level CPT codes instead of reviewing patient record documentation & coding manual to determine the proper code. Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day, states Medicare Claims Processing Manual, Chapter 12, Section 40.7. Examples featuring indicator 9. The global surgical package does not include treatment for postoperative complications which requires a return trip to the operating room (OR), according to Medicare Claims Processing Manual, Chapter 12, Section 40.1.B. Use the highest level of specificity of ICD 10 codes to support your E/M level. As per existing medical billing guidelines, you cannot fragment a service into parts and code each component separately. All approved for group A CE credits. NCCI, Part One: When Can You Unbundle? 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. So read through this blog to learn the two most common medical coding mistakes and our other suggestions. Modifier JW Drug amount discarded/not administered to any patient is not limited to use for Medicare claims. Unbundling is also known as fragmentation, i.e, the provider is taking a medical procedure that could be billed with one code and fragmenting it into multiple codes, to add up to a higher reimbursement. Medical billing and coding companies have highly skilled billers and coders on boarded, they can assure you that the provider receive payment for the work they performed. Outsource Strategies International is one of the leading medical billing and coding companies in the medical outsourcing space focused on all aspects of revenue cycle management. Contact Us for a Free, Confidential Consultation. Roughly a third of stays for heart failure and shock (MS-DRG 291), pneumonia (MS-DRG 193) and renal failure (MS-DRG 682) had comparatively short lengths of stay, according to the OIG, indicating hospitals may have engaged in upcoding and caused Medicare to overpay for those stays. EndoGastrics device could be implanted through two procedures, one more invasive and more expensive than the other. The service or procedure was provided to the patient more than once. 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. The same patient then has a left-eye cataract extraction (again, 66984) by the same physician during the global period for the first procedure. Unbundlingbilling separately for multiple components of a procedure that should be billed as a single charge. That factor is expressed in billing rules that govern bundling and unbundling of services. 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.. Compensation for any special damages including litigation costs and reasonable attorneys fees. Use of modifiers. 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. Immediate surgery is scheduled. 2002 2023. That code is used when the insertion is not part of another medical procedure. A common type of upcoding is to use a modifier code to indicate that additional services were provided when those services are actually covered by the standard code for the patient visit. 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. You may append modifier 25 to an E/M code reported on the same date as a minor surgical procedure code, which is a code with global period indicator 000 or 010 on the Medicare Physician Fee Schedule (MPFS), according to Chapter I.E of the Medicare NCCI manual. An Advance Beneficiary Notice of Noncoverage (ABN) form helps a beneficiary decide whether to get an item or service that Medicare may not cover. Government and private insurers use these codes to determine how much to pay for the services and procedures. After investigating the allegations made in the qui tam complaint, the government will decide whether to intervene in, or join, the qui tam lawsuit and pursue litigation. Medisys Data Solutions RCM solutions ensures that the providers recover every $ they are entitled to. An E/M is not separately reportable in this scenario. Tenet settled the lawsuit for $900 million. Should they be billed as a single procedure or as two procedures? With EHR software, providers can copy and paste notes from a patients previous visit into each current treatment note, which can make it appear that the provider has diagnosed and treated every condition on that list. He also ensures to submit accurate claims conveying the necessary information to the payer, preventing fraud risk and maximizing reimbursement. A: Never. Medical To avoid the medical coding mistake of unbundling, here is what you need to do: However, there can be exceptions to unbundling. However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. Two important categories are pricing modifiers (also called payment-impacting modifiers or reimbursement modifiers) and informational modifiers. For unrelated procedures during the postoperative period, the CPT code set provides modifier 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period. To Bundle or Not to Bundle in Medical Billing - dummies