Medicare and other payers are charged with paying only for those services that are medically reasonable and necessary. We are all aware of the restrictions placed on appropriate billing circumstances, including local coverage determinations and prior authorizations (subjects of other articles). For rules surrounding bundling/unbundling, the payers have taken this general concept to the point of being obsessed with the idea that physicians should not be paid twice for any service provided. Therefore, if under any circumstance, one procedure overlaps or duplicates services being paid for by paying for a primary procedure at the same encounter, the procedure is bundled by rule.
The CCI and the private payer datasets have been developed with a combination of interpreting the CPT code manuals and descriptions and a review of billing patterns. The datasets are all based on the average case and/or the volume of services billed in conjunction with other services. The combination of these two approaches has led to many bundling pairs that are either generally inaccurate or not applicable to all circumstances. As an accommodation to these acknowledged shortfalls, the database includes situational accommodation, and modifiers have been added to allow for appropriate reporting of these circumstances when appropriate.
For the published Medicare CCI, if a coded service is considered to always be a part of a second procedure/service (two procedures that overlap in services), the bundling edits will read “unbundling never allowed.” However, if it is determined that under certain circumstances, performing the procedure does not duplicate services performed in the primary procedure (two procedures with no overlap of services), the bundling edits will read “unbundling allowed w/ modifier.” Private payer datasets also contain these accommodations but may not be published or easily identified without direct challenge through billing.
In order to consider reporting two services that pass the concept test above, you will need to document both the details of the procedure (to prove that you performed the procedure) and the reason for performing the procedure (to prove medical necessity). (What’s obvious to you may not be obvious to the reviewer hired by the payer.) If the rest of the billing is handed off to the billing department, the “circumstances” for that particular encounter should be conveyed as well.
If a second procedure was performed for a different reason or circumstance, then you need to communicate the reason so the billing department will understand the appropriate way to bill in order to ensure you are paid for that service.
As it is difficult to remember which codes are a part of the bundling rules and which are not part of the rule set, it is important to establish a process to determine when a modifier should be added and which one. It is recommended the codes selected for reporting the service are double checked to be sure they are correct and complete and the appropriate documentation is included. The next step will be to check the bundling edits using a database such as AUACodingToday or the payer website if available. Most people find the “Bundling Matrix” included in AUACodingToday to be the easiest and fastest way to check.
If the codes are bundled by rule, the use of a modifier will be required. If the codes are not bundled by rule, the services can be reported on separate claim lines using –51 for lower valued procedures for non-Medicare payers, which routinely incorrectly pay for the services billed.
Next: Choose the correct modifier