If you dont append modifier 59, the insurance company would assume that the biopsy and excision involved the same lesion. Depending on payer rules, the number of modifiers required, and the space available, it may be appropriate to append modifier 99 Multiple modifiers to the code and then place additional modifiers in another section of the claim, such as CMS 1500 box 19. A high severity level requires that there be at least one secondary diagnosis that is considered a major complication or comorbidity, such as acute respiratory failure and sepsis. One payers list of pricing and informational modifiers may not match anothers list, so medical coders need to stay current on individual payer policy to avoid incorrect modifier placement that could affect claim processing. When the third code exists, it is the correct code when the procedures are performed together. The PCTC IND (PC/TC Indicator) column in the MPFS relative value files reveals whether a code has a PC/TC split and whether you may append modifiers 26 and TC to the code. NCCI stands for National Correct Coding Initiative. The documentation must clearly show that the provider performed extra E/M work beyond the usual work required for the other procedure or service on the same date. A common type of upcoding is using an E&M code for a more complex and time intensive patient visit than was actually provided. A new postoperative period begins when you report that next procedure in the series. International Society of Refractive Surgery, Unrelated procedure or service by the same physician during the postoperative period. The rationale for the third code is that it takes less total time to perform procedures together than to perform them at separate times. Maximizing Your Revenue with Our Medical Billing Services in Ohio, Outsourcing Mental Health Billing Services The Key to Improving Your Practice, Key Factors in Choosing Oncology Billing Company, General Requirements for Medicaid Providers in Florida. Although separate diagnoses are not required, experienced coders have found that linking one ICD-10-CM code to the procedure/service code and another ICD-10-CM code to the E/M code may speed claim processing. Generally speaking, doctors make more when they unbundle services. Contact Us for a Free, Confidential Consultation. Duke paid $1,000,000 after it was accused of unbundling cardiac and anesthesia services. Modifier 59 is needed to unbundle an NCCI edit. Thats because the guidelines for Medicaid billing depend on the state, so the claim submission formalities also, Keeping your facility in compliance with HIPAAs regulations is crucial for any Florida medical practice. Each NCCI edit signifies a pair of services or procedures that normally should not both be billed when performed by the same provider on the same patient on the same day. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Modifier 57 indicates that this is the exam to determine the need for surgery. 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. This specificity gives auditors, payers, and providers more information to help them determine which type of reporting is prone to errors. Therefore, the code with the highest allowablein this case, vitrectomy should be listed first. Append modifier GZ when you expect Medicare to deny payment of the item or service because it is medically unnecessary, and you issued no ABN. In their bundling guidelines, Blue Cross Blue Shield of North Carolina lists services considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance, which are not eligible for separate reimbursement: According to the AAPC, a clear understanding of the differences between the rules pertaining to coding, billing, and reimbursement is necessary to know when unbundling can turn potentially problematic. Healthcare providers use billing codes to identify the services and procedures that they provide to patients. Loralee joined MOS Revenue Cycle Management Division in October 2021. The provider is not employed by the hospice. In fact, the AAPC notes that, Separate reporting of bundled services is not impermissible unbundling when separate reporting was not intended to, and does not reasonably lead to, improper reimbursement. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. A upcoded bill can be sent to any payerwhether a private health insurer, Medicaid, Medicare, or the patient. The AMAs CPT codes are incorporated into the Healthcare Common Procedure Coding System (HCPCS) codes required for Medicare and Medicaid billing. Use current codes; the use of deleted ICD10 and CPT codes will prolong payments. MPFS relative value files of course include relative value units (RVUs), but those files also provide information essential to proper use of the modifiers below for Medicare claims. Correct coding: CPT code 66984RT (for the cataract removal) and CPT code 6682159LT (for the Nd:YAG). The code that appears in column 1 generally represents the major procedure or service. Unbundling or fragmenting billing codes illegally increases a providers profits by billing bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid. Unbundling is a form of medical billing fraud that is similar to upcoding. You and your staff work hard to deliver your patients the best possible medical care. You may use this modifier combined with modifier GX. A modifier also may provide details not included in the code descriptor, such as the anatomic location of the procedure. Have Knowledge That a Provider Is Unbundling? The two codes in a NCCI edits are bundled together when physicians 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. Those inpatient stays cost Medicare $54.6 billion that year. ICD-10 and CPT code manuals are updated annually. Keep up on our always evolving healthcare industry rules and regulations and industry updates. The NCCI table shows that CPT code 92020 Gonioscopy became bundled with CPT code 65855 Argon laser trabeculoplasty or selective laser trabeculoplasty on Jan. 1, 1996, with an indicator of 1. Individual modifiers may be appropriate only with certain codes, so be sure to check the rules specific to the case youre reporting. Immediate surgery is scheduled. Upcoding occurs when a healthcare provider submits codes to Medicare, Medicaid or private insurers for more serious (and more expensive) diagnoses or procedures than the provider actually diagnosed or performed. One way to ensure that you dont inadvertently step onto an unbundling/ upcoding time bomb is to work with a professional medical coding and billing service with an established reputation in the industry. In addition to separating modifiers based on whether theyre from the CPT or HCPCS Level II code set, modifiers are also categorized by type. However, your MAC and many other payers may instruct you not to append modifier 51 to codes. In addition to modifiers 26 and TC, the Medicare relative value files include modifier 53 Discontinued procedure. So read through this blog to learn the two most common medical coding mistakes and our other suggestions. The modifier provides additional information about Medicares Global Surgery Booklet provides these examples: The TEAM SURG (Team Surgery) column is connected to modifier 66 Surgical team. Improper medical billing is just one method of defrauding government healthcare programs. The FCA also protects whistleblowers from the risk of employer retaliation. However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. Upcoding and unbundling are methods of healthcare billing fraud involving the improper application of codes for medical diagnoses and procedures. Instead, they often occur alongside other illegal, unethical, or fraudulent billing practices. NCCI edits are used to review claims prior to payment. When unbundling is deemed appropriate, modifier 59 Distinct procedural service should be appended to the code in column 2. That code is used when the insertion is not part of another medical procedure. CMSs definition of an unbundled lab test 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. You do not need to submit a copy of the ABN to Medicare, but you must have it available on request. A very common example is a trigger point injection (TPI). Modifier 59, referenced in the previous section, is just one of the modifiers that can bypass an NCCI edit. Vitrectomy (67036) and cataract extraction (66984) are bundled. NINE INSTRUCTION COURSES. Access: Academy Plus course pass required. For Medicare, professional claims use place of service (POS) 02 Telehealth to indicate the service was a telehealth service from a distant site (but see Note below). In other words, it will take hard work. Upcoding is when a healthcare service provider uses the billing code for a more expensive procedure when, in reality, a less expensive procedure was performed. For team surgeons using modifier 66, the Global Surgery Booklet advises that claims must have enough information to allow the MAC to determine pricing by report. For assistant-at-surgery services by physicians, the Medicare rate is 16% of the surgical payment. If the government decides not to intervene in a qui tam case, whistleblowers and their counsel may then pursue the litigation on their own and recover funds on behalf of the government. An example from the National Correct Coding Initiative (NCCI) Policy Manual further illustrates the logic that supports bundling: CPT 36000 Introduction of needle or Many states have employment laws that may provide other remedies for wrongful discharge or other such discrimination. Studies of medical billing fraud make it clear that upcoding fraud and unbundling fraud dont happen in a vacuum. Enjoy hands-on ICD-10 training. Another important global package modifier is modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period. about a potential case to Phillips & Cohen LLP, we do not become your attorneys. In FY 2019, hospitals billed Medicare for hospital stays at the highest severity level for 40% of all 8.7 million Medicare inpatient cases. The two codes can be unbundled when the column 2 code represents one of the following: When unbundling, use modifier 59. The patient returns during the biopsys global period for suture removal and, on the same date, has a distinct E/M visit with the physician to discuss the diagnosis and treatment options.