Part B Insider (Multispecialty) Coding Alert

Unbundling and Double-Billing Go Hand-In-Hand with Upcoding

Published on Tue Feb 21, 2017

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Look to modifiers to avoid claims denials in these cases.

Coordinated care is at the heart of MACRA’s Quality Payment Program (QPP), and at the heart of coordinated care is bundling. As the CMS Innovation Center continues to put forth more and more bundling packages to maximize quality and physician cooperation, you need take into account these evolving measures to avoid coding errors.

Risky business: As bundling continues to be the preferred means of payment with many new CMS initiatives, the desire to unbundle payments for financial gain abounds. However, this has been a long standing problem with Medicare providers, who have tried in the past to use two CPT^®codes when one should have been used or who send out numerous bills when a single bill covers the care under one global period.

Tip: Oftentimes, the modifier that’s added on to the procedural code clarifies why you’ve coded something a particular way. If you unbundle codes, the modifier explains the necessity for doing so and can help you avoid a denial.

“Practices should review CMS guidance in the applicable clinical areas to determine where services have been bundled,” says John E. Morrone, Esq, a partner at Frier Levitt Attorneys at Law in Pine Brook, NJ. “The 2017 Physician Fee Schedule guidance provides a useful resource to determine which codes have been aggregated into bundled payments.”

Double trouble: In a duplicate billing situation, the provider bills both CMS and the recipient or private insurer for the same service. Double-billing also occurs when two providers charge for the same service on the same day.

For instance: An example of this would be if you sent a patient to an outside lab for a urinalysis, but then your practice and the lab both billed 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) for the service. Only the lab should bill the charge if you didn’t perform the urinalysis.

Resource: Review the 2017 Medicare Physician Fee Schedule (MPFS) here: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-26668.pdf.