Medical Billers and Coders Logo

Article-What-is-Unbundling-in-Medical-Billing.jpg

What is Unbundling in Medical Billing?

When there is a single code available that captures payment for the component parts of a procedure, only that procedure code should be used. Unbundling refers to using multiple procedure (CPT) codes for the individual parts of the procedure, either due to misunderstanding or in an effort to increase payment. Unbundling also occurs when a coder charges for two services when the code for the major service assumes that the minor service is also provided. Since two charges will result in a larger bill than a single comprehensive charge, unbundling results in overbilling. Unbundling may be caused by a coder who does not understand the CPT coding system or he/she is not certified. Repeated unbundling can be a red flag and could attract an external payer audit. In this article, we will be answering the question ‘What is Unbundling in Medical Billing?’ by using some of the examples suggested by the Centers for Medicare & Medicaid Services (CMS).

Examples of Unbundling

The CMS developed the National Correct Coding Initiative (NCCI) program to prevent inappropriate payment of services that should not be reported together. We referred to some of the examples from the NCCI document to explain in detail, what is unbundling in medical billing?

  • A provider/supplier shall not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services. For example, if a physician performs a vaginal hysterectomy on a uterus weighing less than 250 grams with bilateral salpingo-oophorectomy, the provider/supplier shall report CPT code 58262 (Vaginal hysterectomy, for a uterus 250 g or less; with the removal of tube(s), and/or ovary(s)). The provider/supplier shall not report CPT code 58260 (Vaginal hysterectomy, for uterus 250 g or less ;) plus CPT code 58720 (Salpingo-oophorectomy, complete or partial, unilateral, or bilateral (separate procedure)).
  • A physician shall not fragment a procedure into component parts. For example, if a physician performs an anal endoscopy with biopsy, the provider/supplier shall report CPT code 46606 (Anoscopy; with biopsy, single or multiple). It is improper to unbundle this procedure and report CPT code 46600 (Anoscopy; diagnostic...) plus CPT code 45100 (Biopsy of the anorectal wall, anal approach...). The latter code is not intended to be used with an endoscopic procedure code.
  • A provider/supplier shall not unbundle a bilateral procedure code into 2 unilateral procedure codes. For example, if a physician performs bilateral mammography, the provider/supplier shall report CPT code 77066 (Diagnostic mammography... bilateral). The provider/supplier shall not report CPT code 77065 (Diagnostic mammography... unilateral) with 2 UOS or 77065 LT plus 77065 RT.
  • A provider/supplier shall not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure. A provider/supplier shall not report CPT code 49000 (Exploratory laparotomy...) when performing an open abdominal procedure such as a total abdominal colectomy (e.g., CPT code 44150).
  • Providers/suppliers shall only report a biopsy separately when pathologic examination results in a decision to immediately proceed with a more extensive procedure (e.g., excision, destruction, removal) on the same lesion; or when performed on a separate lesion.
  • Providers/suppliers shall not report a biopsy separately when it is to assess resection margins or to verify resectability; or when performed and submitted for pathologic evaluation completed after performing the more extensive procedure.

Up-Coding

An HCPCS/CPT code may be reported only if all services described by that code have been performed. For example, if a physician performs a superficial axillary lymphadenectomy (CPT code 38740), the provider/supplier shall not report CPT code 38745 (Axillary lymphadenectomy; complete). Each HCPCS/CPT code has a defined unit of service for reporting purposes. A provider/supplier shall not report UOS for an HCPCS/CPT code using a criterion that differs from the code’s defined unit of service. For example, some therapy codes are reported in fifteen-minute increments (e.g., CPT codes 97110-97124). Others are reported per session (e.g., CPT codes 92507, and 92508). A provider/supplier shall not report a per-session code using fifteen-minute increments. CPT code 92507 or 92508 should be reported with one unit of service on a single date of service. Providers/suppliers must avoid up-coding at any cost.

Down-Coding

If an HCPCS/CPT code exists that describes the services performed, the providers must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code. For example, if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the provider/supplier shall report CPT code 19302 (Mastectomy, partial...; with axillary lymphadenectomy). A provider/supplier shall not report CPT code 19301 (Mastectomy, partial...) plus CPT code 38745 (Axillary lymphadenectomy; complete). Providers/suppliers generally do down-coding due to fear of coding compliances.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing services. In this article, we tried answering the question ‘What is Unbundling in Medical Billing?’ by sharing correct coding examples from CMS’s NCCI document. If you are looking for professional assistance with medical coding, we can assist.

Our certified coders will ensure that every single procedure is coded appropriately without unbundling the codes. To know more about our medical specialty-wise coding services, call us at: 888-357-3226 or email us at: info@medicalbillersandcoders.com.


Published By - Medical Billers and Coders
Published Date - Dec-20-2022 Back

Looking for a Medical Billing Quote?

Are you looking for more than one billing quotes?

Yes

No

Looking for a Medical Billing Quote?

Are you looking for more than one billing quotes ?

Yes

No

×

THANK YOU!

Would You like to Increase Your Collections?

Yes