Wiki Bundled Codes - Medicare

[lebanon52]

Hello All;

If a claim went out coded incorrectly resulting in 2 of the 3 codes being bundled, is it improper to refund medicare the 3rd code and rebill with the first 2 that are not bundled?

Thanks for guidance.

Have a good weekend!!!

 

[JenniferB7]

If the claim was coded incorrectly, then you are required to refund Medicare the amount you were paid in error and file a corrected claim with the correct codes. The key words being "coded incorrectly." Your coding must correctly reflect the services performed. You cannot, however, change the codes so that you get paid for two codes instead of one, when one code correctly explains what was done. For example, you cannot separately bill for a tonsillectomy (CPT 42825) and an adenoidectomy (CPT 42830) because there is one code that accurately describes the service: tonsillectomy and adenoidectomy (CPT 42820). This would be unbundling and would be a violation of the False Claim Act.

Hope that helps!

 

[smh1312]

Reopening

If you simply coded one of the procedures incorrectly this falls under a Medicare reopening. You can call the Medicare phone reopening line to correct the code and the charge amount. Then ask them to reprocess the whole claim. It is not necessary to refund Medicare first. Another option to correct your claim is thru the self service reopening online, if that is an option in your area. I'm in Jurisdiction F and we us the Noridian Medicare Portal to view eligibility, claims, appeals, and a few others. This website has saved me a lot of time when working my Medicare AR.

 

[JenniferB7]

It depends on your Medicare Administrative Contractor (MAC).

I agree with smh1312. If your MAC allows you to change your charges/units as part of a reopening request, then you can submit a reopening request and it is much easier than filing a corrected claim. I know my local MAC just recently (this year) started accepting reopening requests that allowed changes to the charges/units, though some CPT code changes (like new patient E/M codes) are still not allowed. If the change is not allowed by reopening, then you will need to file a corrected claim. The same applies to the refund. I have worked with MACs that have told me to wait until they request the refund and others that have told me to submit a voluntary refund.

The law states you have to refund within 60 days of identification of an overpayment, which is what I follow (and recommend to others) unless my (or your) MAC tells me otherwise. If so, document date and time of the call, who you spoke with, and the specific instructions you were given. Hope that clarification helps!