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).
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?
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.
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.
