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What is Unbundling in Medical Billing?

What is Unbundling in Medical Billing

Unbundling coders are using multiple CPT codes for parts of a procedure, is one of the most common medical coding error identified by AMA in 2018. All medical billing and coding companies should differentiate between when separate reporting of services is correct coding and when such reporting becomes fraudulent. Unbundling in medical billing is billing for procedures separately.

Unbundling normally covered by single and comprehensive CPT code. Pairs of codes should not be billed together. This edit is published by The Centers for Medicare and Medicaid National Correct Coding Initiative. To NCCI is continually working towards to prevent wrong coding and fraudulent claims.

The two codes in a NCCI edits are “bundled” together when physician’s paid of service or procedure that are normally not billed together when performed by the same physician on the same patient on the same day. Unbundling comes in picture when multiple CPT codes are used to report components of parts of the procedure, either unintentionally or in order to increase payment.

As per AAPC, a clear understanding of the differences in the rules pertaining to coding, billing and reimbursement are necessary to know when unbundling can turn potentially difficult. Do you know when unbundling is permissible? Here are some examples provided by the American Academy of Ophthalmology demonstrating how to unbundle NCCI edits:

A patient has pterygium surgery in the right eye. During the 90-day global period, the patient is hit in the left eye with a bungee cord, causing a traumatic cataract and vitreous hemorrhage. Immediate surgery is scheduled.

Vitrectomy (67036) and cataract extraction (66984) are bundled. In this case, it is appropriate to append modifier -59 to unbundle since it was known preoperatively that the patient needed both procedures. Modifier -59 should be appended to CPT code 66984 because this is the secondary procedure submitted on the claim due to its lower allowable. Modifier 79 should be used to indicate that cataract removal and vitrectomy are unrelated to the pterygium surgery. To do error free coding, outsource medical billing to an expert and leading medical billing company. 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. 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. He also ensures to submit accurate claims conveying the necessary information to the payer, preventing fraud risk and maximizing reimbursement.

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