Master Bundling Basics
Gain confidence in knowing when to bundle services and when to bill services separately.
Bundling occurs when a procedure or service with a unique CPT® or HCPCS Level II code is included as part of a “more extensive” procedure or service provided at the same time. Unbundling errors—coding separately for procedures that should have been bundled—are a frequent cause of claims denials and negative audit findings. Conversely, unnecessary bundling has a negative effect on reimbursement. Luckily, a little knowledge and an easy-to-access resource are all you need to master bundling basics.
How Bundling Works
A popular Chinese restaurant in my neighborhood offers a $7.99 lunch special that includes an entrée, rice, an eggroll, and a medium drink. If you’re not that hungry, you can order à la carte (for instance, just an eggroll and a drink), and the cashier will ring up each item separately.
Bundling in coding works the same way. For example, you may code separately for a diagnostic endoscopy provided “à la carte.” But if diagnostic endoscopy precedes surgical endoscopy of the same type, per CPT® rules, the surgical scope includes the diagnostic scope. Only the surgical scope may be reported. As with the lunch special, one price covers everything.
Any designated “separate procedure” is bundled when provided with another service/procedure in the same anatomical location. For example, 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) may be reported by itself to describe excision of adhesions. You would not, however, report (or be paid for) 29884 separately with another arthroscopic procedure in the same knee (e.g., 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)).
An example from the National Correct Coding Initiative (NCCI) Policy Manual further illustrates the logic that supports bundling:
CPT® 36000 Introduction of needle or intracatheter, vein is integral to all nuclear medicine procedures requiring injection of a radiopharmaceutical into a vein. CPT® code 36000 is not separately reportable with these types of nuclear medicine procedures; however, CPT® code 36000 may be reported alone if the only service provided is the introduction of a needle into a vein.
Evaluation and management (E/M) services also may be bundled. All procedures, whether diagnostic or therapeutic, include an “inherent” E/M component, according to the Centers for Medicare & Medicaid Services (CMS) Transmittal 954. This inherent E/M is bundled into the procedure coding. For example, if the physician provides a cursory examination prior to a previously scheduled gastrointestinal (GI) endoscopy (43235 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing (separate procedure)), the exam is built into the endoscopy and is not reported separately.
The alert coder will recognize that there can be exceptions to bundling rules. For instance, per Transmittal 954, you may separately report an E/M service on the same day as another procedure if documentation substantiates that the E/M is “significant, separately identifiable … [and] is above and beyond the usual pre- and post-operative work for the service.” You also must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to the E/M code to identify the service as distinct from other, same-day procedures/services.
NCCI: The Ultimate Bundling Reference
For Medicare payers (and many commercial payers), the end-all, be-all bundling resource is the NCCI. CMS updates the NCCI each quarter (Jan. 1, April 1, etc.), and posts the complete list of edits, as the bundled code pairs are called, as a free download. You also may purchase a subscription to NCCI, in electronic or paper format, from National Technical Information Service (NTIS). Be sure that you always refer to the most up-to-date version of NCCI when checking for code bundles.
NCCI contains two kinds of edits. The first of these are the bundling edits, called “Column 1/Column 2” or “correct coding” edits (see the accompanying “NCCI Mutually Exclusive Edit Pairs” sidebar for a brief explanation of the second kind of NCCI edits). Codes listed in Column 2 normally are bundled to the code listed in Column 1, which is the “more extensive” procedure. Not every CPT® or HCPCS Level II code is subject to bundling edits, but a single Column 1 code may bundle dozens of Column 2 codes.
Consider this partial example of bundling edits (available in the CPT® Codes 20000-29999 – Column1/Column2 .zip file:
|Column 1||Column 2|
From this example, we learn that if the physician performs deep muscle biopsy (20205 Biopsy, muscle; deep), then wound exploration (20103 Exploration of penetrating wound (separate procedure); neck), superficial biopsy (20200 Biopsy, muscle; superficial), and manipulation under anesthesia (24300 Manipulation, elbow, under anesthesia) at the same location are included. Hypothetically, if a surgeon performs deep muscle biopsy of the left bicep and explores the wound at the same time, only the deep biopsy is reported.
Here’s a second, edited example:
|Column 1||Column 2|
In this case, we see that cervical arthrodesis below C2 (22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) includes injection for discography (62291 Injection procedure for discography, each level; cervical or thoracic) and single injection of diagnostic or therapeutic substances, not including neurolytic substances (62310 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), or diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic and 62311 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), or diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)) when performed at the same spinal location.
Know When NOT to Bundle
Code bundles aren’t always absolute. A code that normally is bundled may be reported (and reimbursed) separately if both of the following conditions are met:
1. The NCCI code pair edit includes a “1” modifier indicator.
Look again at our NCCI code pair examples shown above. Notice that each Column 2 code includes a superscript “1” or “0.” This number is called the modifier indicator. Those codes with a “0” modifier indicator may never be reported separately with the Column 1 code. For example, the 22551/62310 code pair edit has been assigned a “0” modifier indicator, so there are no circumstances under which you may report 62310 separately with 22551.
Those codes assigned a “1” modifier indicator may be reported and reimbursed separately from the Column 1 code, provided the second condition also is met.
2. The Column 2 procedure must be separate.
This can happen, for instance, if the two procedures occur at separate anatomic sites, or during separate patient encounters. For example, suppose the physician performs deep muscle biopsy (20205) on the left bicep, and performs wound exploration (20103) at a different location (such as the right thigh). Because 20205 has been assigned a modifier indicator of “1,” and the two procedures occurred at separate locations, the procedures may be reported (and reimbursed) independently.
Modifiers Seal the Deal
When you unbundle an NCCI code pair edit, you must append a proper modifier to the Column 2 code. In our previous example for deep muscle biopsy on the left bicep and wound exploration on the right, proper coding is 20205, 20103-59.
Without a modifier, payers will automatically reject the Column 2 code, rendering it bundled and not separately payable. In the majority of cases, per the NCCI Policy Manual, modifier 59 Distinct procedural service “is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.” Here’s another example for modifier 59 usage:
The Column 1/Column 2 code edit with Column 1 CPT® code 38221 Bone marrow; biopsy, needle or trocar and column two CPT® code 38220 Bone marrow, aspiration only includes two distinct procedures when performed at separate anatomic sites or separate patient encounters. In these circumstances, it would be acceptable to use modifier 59; however, if both 38221 and 38220 are performed through the same skin incision at the same patient encounter, modifier 59 should NOT be used.
When reporting a significant, separately identifiable E/M service on the same day as a procedure, you should append modifier 25 to an E/M that accompanies a minor procedure (one with 0, 10, or “XXX” global period designation); or modifier 57 Decision for surgery to an E/M service that accompanies a major procedure (one with a 90-day global period).
Learn more: For additional information on applying modifiers 25 and 57, see “Wisely Choose Between Modifier 25 and Modifier 57,” September 2010 Coding Edge, pages 22-24.
The Bottom Line
Bundled code pairs are not rare. The NCCI contains thousands upon thousands of bundling edits (22551, alone, bundles over 100 codes). Specialized coding and billing software will alert you to possible bundling edits, but remember: Eternal vigilance is the price of proper coding.
NCCI Mutually Exclusive Edit Pairs
NCCI includes two types of edits. The first is bundling edits, which we focus on in the main article. The second is called “mutually exclusive edits.” Mutually exclusive edits describe code pairs that would not reasonably be performed at the same session and anatomic location for the same patient. As explained by the NCCI Policy Manual, “An example of a mutually exclusive situation is the repair of an organ that can be performed by two different methods. Only one method can be chosen to repair the organ. A second example is a service that can be reported as an ‘initial’ service or a ‘subsequent’ service. With the exception of drug administration services, the initial service and subsequent service cannot be reported at the same patient encounter.”
Mutually exclusive code pairs are listed in two columns. As with bundling edits, mutually exclusive code pair edits may be bypassed if the edit includes a “1” modifier indicator, and if the procedures are performed at different anatomical sites or during separate patient encounters (for example, if a procedure is provided on contralateral structures, such as the left and right eye, or left and right knee, etc.). As with bundling edits, you must append an appropriate modifier (usually modifier 59) to the Column 2 code to designate the procedures as separate and distinct. Documentation must support separate coding for the procedures.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.