Internal Medicine Coding Alert

Beware: Absent CCI edit doesnt make separately codeable a shoo-in.

Even if CCI doesnt publish edits bundling two procedures together, youve got to check that separate reporting is allowed, or you could face fraud charges.

Edits do not address every possible coding situation, which means you must still report the most applicable and most accurate code(s) for your physicians documentation. To avoid unbundling or missing allowed combos not found in the Correct Coding Initiative (CCI), follow these best practices.

Follow the CCI Road

The CCI manuals introduction specifies that edits were not created to address every situation involving improper unbundling, says Seth Canterbury, CPC, ACSEM,education specialist with the University of Florida Jacksonville Physicians, Inc. This fact does not absolve the practice from coding a service correctly -- that is, applying the standard bundling/unbundling principles -- when submitting codes.

The edits and policies do not include all possible combinations of correct coding edits or types of unbundling that exist, states the CCI manual. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination.

Take CPT to Heart

You wouldnt be off the hook, even if Medicares Correct Coding Initiative and its bundling edits didn't exist, Canterbury says. The CPT books introduction refers to instructions included with many codes indicating whether it is proper or not to submit a code with another code or codes.

CPT states, When reporting codes for services provided, it is important to assure the accuracy and quality of coding through verification of the intent of the code by use of the related guidelines, parenthetical instructions,and coding resources, including CPT Assistant and other publications resulting from collaborative efforts of the AMA with medical specialty societies.

Impact: Medicare may not have created a specific edit to prevent coders from separately billing something that is clearly an always-included component of a comprehensive procedure, Canterbury notes. But, it would be improper to just bill away, as it is not only the specific edits themselves, but the principles behind the edits (as stated in Medicares National Correct Coding Initiative Manual) that must be considered, along with any information in the CPT book that discusses the appropriateness of reporting one code with another, Canterbury says.

Beware Potential Bundling/Unbundling Fraud

You may assume that if your carrier pays your unbundled charges, then your carrier approves of them. That is not necessarily the case. Auditors may come back to you after the fact and investigate whether you coded correctly.

I worked on an expert witness team for a physician indicted of criminal fraud, says Barbara J. Cobuzzi,MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC,president of CRN Healthcare Solutions in Tinton Falls, N.J. One of the charges was unbundling and some of the unbundling accusations werent even CCI edits, but convention.

During the fraud indictment, the U.S. Attorneys office calculated the physician overcharged nearly half a million dollars, all based on the governments belief that certain codes should not be billed together, whether or not CCI publishes advice against it, Cobuzzi says.

Bottom line: Never bill Medicare for services that are considered bundled under the CCI guidelines unless they meet the pre-specified criteria allowable (such as separate encounter, separate location). Otherwise, your insurer could consider it fraudulent coding, even if the payer doesnt reimburse you for the charge.