Wiki HCPCS Level II Coding in an OBL POS 11

[lbouz]

Seeking clarification on medication, supply and device coding for procedures performed in an outpatient based lab POS 11. Some CPT codes indicate these items are bundled / included in the primary code. Should all HCPCS Level II codes be included / itemized on the bill even if payment is bundled?

 

[thomas7331]

Seeking clarification on medication, supply and device coding for procedures performed in an outpatient based lab POS 11. Some CPT codes indicate these items are bundled / included in the primary code. Should all HCPCS Level II codes be included / itemized on the bill even if payment is bundled?

There's a fine distinction between what's bundled under CPT descriptions and what's bundled for payment. If CPT guidelines indicate that a code includes certain services, then it's inappropriate and incorrect coding to report those services a second time with a separate incidental code (unless of course the documentation supports unbundling with a modifier due to specific circumstances). Bundling for 'payment', though, is a matter of payer reimbursement policy, such as NCCI. Individual payers may consider their payment for a given service to include related services or items even when the CPT descriptions or guidelines don't specifically state that those things are included. In this situation, you can report those services separately since you aren't duplicating your reporting and are still following correct coding guidelines, but they may be denied as inclusive based on payer policy. But to bypass the payer edits in these cases, you still must be able to support your modifiers with documentation that shows those incidental services meet the payers' requirements for separate or additional payment.

This can be a confusing distinction, but hopefully this is clear. If you have some specific coding examples or scenarios that could be looked at for discussion, that might be helpful.