1. You and your staff work hard to deliver your patients the best possible medical care. For a link to the CMS edits, go to www.aao.org/coding and click on Coding Tools, and then CCI Edits.. Here are six medical coding errors and how to prevent them in your practice. Tenet settled the lawsuit for $900 million. A knowledgeable 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, and submit accurate claims conveying the necessary information to the payer, preventing fraud risk and maximizing reimbursement. Each of the tests within a panel have individual and higher billing rates. Modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period is appropriate for use only on E/M codes and only for services unrelated to the original procedure (the one with the global period). Upcoding is fraudulent medical billing in which a bill sent for a health service is more expensive than it should have been based on the service that was performed. NCCI edits are used to review claims prior to payment. You should not use modifier 53 for elective cancellation of a procedure before anesthesia induction or surgical preparation in the operating suite. While each of these modifiers is important, a few deserve special attention because theyre among the most used (or misused). Americans spent over $3.5 trillion on healthcare in 2017, and fraudulent medical billing practices may account for as much as 3% of that spending, according to the National Healthcare Anti-Fraud Association. Here is an example of when to use modifier 25 based on a scenario in Medicare Claims Processing Manual, Chapter 12, Section 40.1.C. It could lead to unbundling, and such reporting falls under the purview of fraudulent medical billing. 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). 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. Individual payers may provide additional guidance. The separate ICD-10-CM codes make the distinct reasons for the E/M and other procedure or service more obvious. Part of that includes ensuring there arent any billing errors causing damage to the bottom line. Coding SOS. 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. Billing a telehealth patient for an office visit. These are examples of some of the most commonly used CPT modifiers: Youll find CPT modifiers listed in your CPT code book. Note that informational modifiers may affect whether a code gets reimbursed, so they may be relevant to payment, despite the name informational. For instance, coders often use modifier 59 to override Medicares National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits, bringing in payment for both codes in the code edit pair. The False Claims Act gives employees and others who know about upcoding, unbundling and other healthcare fraud a way to report it safely. Use current codes; the use of deleted ICD10 and CPT codes will prolong payments. 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. 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. Check payer policy to confirm, but non-Medicare payers may follow Medicare rules. A new postoperative period begins when you report that next procedure in the series. Use the highest level of specificity of ICD 10 codes to support your E/M level. The use of electronic health records (EHR) software can facilitate upcoding and unbundling. Doctors, including primary care doctors as well as specialty doctors (such as psychiatrists, ophthalmologists, dermatologists, orthopedists, pain management doctors, wound care doctors and others), engage in upcoding when they use codes to reflect more expensive services than the ones they actually provided. Web7. Using the correct CPT code is therefore essential to obtaining the correct payment for services and procedures. We are a group of medical billing experts who offer comprehensive billing and coding services to doctors, physicians & hospitals. Health Care Fraud and Abuse A patient comes for a set of 3 trigger point injections as per the plan, the physician cant bill these injections for an office visit unless the patient presents another problem. After checking allergy and immunization status, the physician performs the procedure. Medical Coding Modifiers - CPT, NCCI & HCPCS Level II - AAPC Before appending modifier GV to a code, you should check these points: Medicare Claims Processing Manual, Chapter 11, Section 40.1.3, provides more information about attending physicians for hospice patients. Pro-fee coders may consider appending modifier 52 Reduced services or modifier 53 Discontinued procedure to a medical code when a provider does not complete the full procedure or service described by that code. A hospital also engages in upcoding when it bills for care as if provided by a physician when it was actually provided by a nurse or physicians assistant, which is a lower-paying service. 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. Keep in mind that payers, including Medicare, may require same-specialty physicians in the same group to bill as if they are a single physician. Is there ever a circumstance in which it is appropriate to unbundle with modifier 59? Correct coding: CPT code 66984RT (for the cataract removal) and CPT code 6682159LT (for the Nd:YAG). Basics of Bundling and Unbundling in Medical Coding by Natalie Tornese | Last updated Dec 2, 2022 | Published on Feb 26, 2019 | Medical Billing | 0 comments. search for instances of unbundling in medical billings. An example of unbundling is billing parts of a single, whole procedure separately. assigning lower level CPT codes instead of reviewing patient record documentation & coding manual to determine the proper code. Instead, they often occur alongside other illegal, unethical, or fraudulent billing practices. Two prevalent and increasingly common methods of perpetrating billing fraud are known as Upcoding and Unbundling.. Prior results do not guarantee a similar outcome. The MPFS relative value files also include columns to indicate Medicares code-specific policies on modifier use and payment when multiple providers perform a procedure at the same session. When: Sunday, Nov. 11, 2-3 p.m. Where: Technology Pavilion (Booth 880). The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code. Modifier 59 Distinct procedural service is a medical coding modifier that indicates documentation supports reporting non-E/M services or procedures together that you normally wouldnt report on the same date. Access: Register in Hall A for $270. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. All medical billing and coding companies should differentiate between when separate reporting of services is correct coding and when such reporting becomes fraudulent. Identical NCCI PTP-associated modifier lists are shown in the National Correct Coding Initiative Policy Manual for Medicare Services available on CMS NCCI edits page and in the National Correct Coding Initiative Manual for Medicaid Services available on the Medicaid NCCI reference documents page. Modifier JW Drug amount discarded/not administered to any patient is not limited to use for Medicare claims. A example of upcoding in healthcare could be a Medicare patient visits a doctor for an annual routine checkup, a service typically 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. That code is used when the insertion is not part of another medical procedure. Explore TEPEZZA (teprotumumab-trbw) nowfor your patients with this serious, progressive disease. This specificity gives auditors, payers, and providers more information to help them determine which type of reporting is prone to errors. Four colonoscopy codes (44388, 45378, G0105, and G0121) have one row for the code and one row for the code with modifier 53. The appropriate level of E&M (9921X57) or Eye code (9201X57). In that case, you should report the 95-unit dose on one line. The question is one that coders must answer by relying on the rules that govern coding. For example, a home healthcare agency that reports more time-intensive services provided to a patient than were actually provided is a type of upcoding. We can help you seek justice and protect your rights throughout the process. Medical billing and coding errors lead to the loss of revenue, claims denial, fines, and federal penalties. Exam Prep - Chapter 5 - Compliance 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. Whistleblowers are entitled to financial reward between 15 and 25% of the total recovery. Medical Billing Fraud: Upcoding & Unbundling Whistleblower When you know preoperatively that both procedures will be performed, it is appropriate to unbundle by appending modifier 59 to 66984. A careful comparison can uncover unbundling errors that result in inflated billing. The False Claims Act also protects healthcare whistleblowers from harassment, discrimination, or retaliation by their employers. Section 1.2 and Section 60.1.1 both state, Coinsurance and deductible are waived for moderate sedation services (reported with G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service and when reported with modifier 33. The MPFS lists fee maximums Medicare uses to pay physicians and other healthcare professionals on a fee-for-service basis. Understanding Unbundling or Fragmenting Medical Billing Codes Consequently, the code in column 2 is generally not payable in addition to the first code because its value is accounted foror bundledin the payment for the code in column 1. 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. For instance, the manual states, When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for professional services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an independent attending physician, who is not an employee of the designated hospice nor receives compensation from the hospice for those services.. Like many healthcare careers, becoming a medical biller and coder will take education and training. Examples of Unbundling The CMS developed the This is a mutually exclusive edit. There are no circumstances in which both procedures of the code pair should be paid. Improper coding also might occur through unbundling or fragmentation. Medicare and Medicaid often will have lower reimbursement rates for groups of procedures commonly performed together, such as incisions and closures incidental to surgeries. CMSs definition of an unbundled lab test Example Of Unbundling History; physical examination; complexity of medical decision making; amount of time spent with the patient; nature of the patient's problem; need for coordination of care; need for counseling and/or teaching. For example if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the provider should report CPT code 19302 (Mastectomy, partial, with axillary lymphadenectomy). Medical billing and coding can be hard at times, but it is by no means impossible. Again, each surgeon reports the code with modifier 62 appended. 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. Other types of healthcare providers also may engage in improper upcoding. The ABN lets the beneficiary know they may be financially liable if Medicare denies payment. Lack of medical necessity is when a physician fails to give the coder accurate information on a patients diagnosis. 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. 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, Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles, Separate structure, a service that is distinct because it was performed on a separate organ/structure, Separate encounter, a service that is distinct because it occurred during a separate encounter, Separate practitioner, a service that is distinct because it was performed by a different practitioner, Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service, Assistant surgeon (when qualified resident surgeon not available), Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery, Tech & Innovation in Healthcare eNewsletter, Unrelated postoperative evaluation and management (E/M) service, Separate E/M on same day as other service, Unplanned postoperative return to the operating room, Multiple same-date outpatient hospital E/M services, Separate encounter, practitioner, structure, service.