With the help of an attorney, whistleblowers can file a qui tam lawsuit, which will trigger a government investigation. Modifier 79 should be used to indicate that cataract removal and vitrectomy are unrelated to the pterygium surgery. The NCCI table shows Other types of healthcare providers also may engage in improper upcoding. By clicking on Request a Call Back button, we assume that you are accepting our Terms and Conditions. All medical billing and coding companies should differentiate between when separate reporting of services is correct coding and when such reporting becomes fraudulent. Upcoding and Unbundling Charges in Medical Billing Modifier KX Requirements specified in the medical policy have been met is appropriate in a variety of circumstances. Health Care Fraud and Abuse Avoid these 2 Common Medical Coding Mistakes At all Costs! Medical billing and coding can be hard at times, but it is by no means impossible. Here are some examples of unbundling from www.outpatientsurgery.net: Billing for a lesion excision and skin repair on a single service date would constitute unbundling and generate an NCCI edit. Modifiers 73 and 74 apply only when the procedure is discontinued due to extenuating circumstances or issues that threaten the wellbeing of the patient. (AMA). At its most basic level, medical billing fraud involves a healthcare provider billing for services it did not provide. Penalties under the FCA can be both civil and criminal, resulting in costly fines and even a prison sentence. Medical Coding Immediate surgery is scheduled. Modifier JW Drug amount discarded/not administered to any patient is not limited to use for Medicare claims. Determining whether an E/M service occurred on the same date of service as another procedure or service is typically straightforward. WebUpcoding Examples in Medical Billing Codes. The coder would then add a modifier to the CPT code to make clear that the cauterization was a distinct service.. You should append modifier 79 to the code for the second procedure. You may use this modifier combined with modifier GY. You enter the pricing modifier directly to the right of the procedure code on the claim. EndoGastric Solutions, Inc., a Washington-based medical device manufacturer, returned $5.25 million to the federal government to settle upcoding allegations. Immediate surgery is scheduled. Note that using modifier 24 to report an E/M related to the underlying disease process may be appropriate. a written agreement, we do not represent you and have not agreed to do so. If the government decides not to intervene in a qui tam case, whistleblowers and their counsel may then pursue the litigation on their own and recover funds on behalf of the government. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules. Medical Coding Errors Similar codes may be available to describe the same service or procedure, depending on a number of factors. Modifier KX is also appropriate on Part B professional claims to identify gender-specific services performed on transgender or intersex patients or those with ambiguous genitalia. Similarly, the NCCI table shows that CPT code 65426 Pterygium excision with graft became bundled with CPT code 66984 Cataract extraction with IOL on July 1, 2001. The list of CLIA-waived tests from CMS provides a long list of CPT lab codes that are appropriate to report with modifier QW. These are examples of some of the most commonly used CPT modifiers: Youll find CPT modifiers listed in your CPT code book. ICD-10 and CPT code manuals are updated annually. In other words, if you removed all the documentation represented by the code for the other procedure or service, would the remaining documentation support reporting an E/M code? The modifier provides additional information about In addition to modifiers 26 and TC, the Medicare relative value files include modifier 53 Discontinued procedure. The United States Attorney General has estimated that Medicare fraud amounted to between $60 and $90 billion per year, with similar levels of fraud affecting Medicare. If two providers try to bill for services provided to the same patient for the same procedures on the same date, its called double billing. For example, the CPT code for surgery to raise or elevate a depressed bone in a simple skull fracture is different from the code used to describe surgery that elevates a compound skull fracture. Waiver of the deductible and coinsurance for ACP is limited to once per year. Since two charges will result in a larger bill than a single comprehensive charge, unbundling results in overbilling. This type of code with a PC/TC split is called a global code (not to be confused with the global period and global surgical package). If a whistleblower faces demotion, harassment or discrimination for bringing attention to medical billing fraud, they are entitled to all relief necessary. For the convenience of the patient, an Nd:YAG capsulotomy is performed on the left eye the same day as cataract surgery on the right eye. Keep in mind some ICD 10 codes must be accompanied by a code first or a second code. With EHR software, providers can copy and paste notes from a patients previous visit into each current treatment note, which can make it appear that the provider has diagnosed and treated every condition on that list. Dont let complex medical billing and coding processes slow you down let us handle it for you! Healthcare providers use billing codes to identify the services and procedures that they provide to patients. The CPT code book Introduction provides these additional examples of when a modifier may be appropriate: Proper use of modifiers is important both for accurate coding and because some modifiers affect reimbursement for the provider. Billing for more expensive durable medical equipment (DME) than provided. Unbundling is the opposite of bundling. WebWhen unbundling is deemed appropriate, modifier 59 Distinct procedural service should be appended to the code in column 2. In addition to separating modifiers based on whether theyre from the CPT or HCPCS Level II code set, modifiers are also categorized by type. A knowledgeable coder will identify and assign the appropriate CPT and/or HCPCS Level II code(s) to correspond to each component of the overall service provided, and submit accurate claims conveying the necessary information to the payer, preventing fraud risk and maximizing reimbursement. The modifier alerts the payer to process the claim as usual despite any gender-specific edits that may apply. The edit has a modifier indicator of 1, which means you may bypass the edit in appropriate clinical circumstances. Providing Medical Necessity. Specialized Medical Billing & Coding Resources, Medicare Alignment for SIM Models through Customized Statewide Models. Access: Register in Hall A for $330. When a patient has a separate E/M service along with a procedure or other service on the same day by the same provider, you may report that E/M code separately for reimbursement by appending modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. Call (404) 550-4615 Today Last Reviewed on Aug. 19, 2022, by AAPC Thought Leadership Team, 2023 AAPC |About | Privacy Policy | Terms & Conditions | Careers | Advertise with Us | Contact Us. You should use modifier GW when a provider renders a service to a patient enrolled in a hospice, and the service is not related to the patients terminal condition. Identical NCCI PTP-associated modifier lists are shown in the National Correct Coding Initiative Policy Manual for Medicare Services available on CMS NCCI edits page and in the National Correct Coding Initiative Manual for Medicaid Services available on the Medicaid NCCI reference documents page. And to make matters worse, medical coding mistakes expose your practice to penalties ranging from thousands to millions of dollars. To do error free coding, outsource medical billing to an expert and leading medical billing company. Billing Fraud Whistleblowers may receive rewards of 15 percent to 30 percent of the amount the government recovers as a result of a qui tam lawsuit. CMS clarifies that not only are these practices unethical, but they can also expose providers to criminal and civil liability. Something that is unethical is not necessarily illegal, but it is in this context. Another name for informational modifiers is statistical modifiers. The policy applies to work performed by same-specialty members of the same group. Copyright 2018 - 2020. Learn what Eye M.D.s must do differently with ICD-10. Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day, states Medicare Claims Processing Manual, Chapter 12, Section 40.7. Medisys Data Solutions Inc. If you need medical coding and billing assistance, examples of upcoding and unbundling multi-million dollar penalties shared by Phillips and Cohen, 6 Basic Points for Medicaid Billing in Any State. Improper medical billing is just one method of defrauding government healthcare programs. She is CPC certified with the American Academy of Professional Coders (AAPC). The global surgical package does not include treatment for postoperative complications which requires a return trip to the operating room (OR), according to Medicare Claims Processing Manual, Chapter 12, Section 40.1.B. CPT guidelines state that appending modifier 53 is appropriate when a patient is scheduled and prepared for a total colonoscopy, but the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances.. Doctors also may use certain modifier codes that show that distinct additional services were provided during a patient visit. When promoting its device, EndoGastric advised providers to bill for the more expensive procedure, causing federal health care programs to pay more than needed. Appending both CPT and HCPCS Level II modifiers to a single code may be appropriate. A patient undergoes pterygium surgery in the right eye. a different session or patient encounter. Medical When decision-making for the procedure or test is done on an office visit, dont bill another E/M when the patient comes back for the test/ procedure. Billing fraud is also the most common form of Medicare fraud. Consequently, for those payers that do not accept modifier 51, the MULT PROC column offers information about expected payment rather than about whether to use modifier 51. Unbundling can also be referred to as fragmentation.. The MPFS splits the work required for a surgery into the PRE OP (Preoperative Percentage), INTRA OP (Intraoperative Percentage), and POST OP (Postoperative Percentage) columns, which show how much of the fee each portion of the surgical work earns in cases where the same provider is not responsible for every aspect of care. That code is used when the insertion is not part of another medical procedure. Medical billers work with (or share the duties of) medical coders. The CPT definition of modifier 59 advises that the modifier may be appropriate for a code when documentation shows at least one of the following: The CPT definition also states that you should not use modifier 59 when a more descriptive modifier is available. Below is an overview of these modifiers. When you know preoperatively that both procedures will be performed, it is appropriate to unbundle by appending modifier 59 to 66984. Unbundling often occurs in medical coding. If you need medical coding and billing assistance,we are just a phone call or email away. Is CPT coding hard? A very common example is a trigger point injection (TPI). A new physician has joined the practice, and an application for a Medicare provider number has been submitted to Medicare for this provider. We $ecure., In the April 10, 2015 guidance, CMS Innovations presented a set of principles that CMS Innovations would consider in read more, Its quite common to receive a request for medical records from insurance carrier who is going to conduct an read more, It is interesting in this economy, with the so-called continued recession, that most of these practices; especially the administrators read more, The shift to value-based care has driven public Medical Billing Fraud: Upcoding & Unbundling Whistleblower This includes healthcare providers reimbursed through government healthcare programs like Medicare and Medicaid. Bring your queries to the Coding Desk at the Academy Resource Center (Booth 508), where you can chat with AAOE experts and browse the AAOEs coding resources, such as the Ophthalmic Coding Series and Ophthalmic Coding Coach. Why Medical Practices Fail to Maximize their Revenue? Modifier 59 Distinct procedural service is a medical coding modifier that indicates documentation supports reporting non-E/M services or procedures together that you normally wouldnt report on the same date. For example, if the closure of the surgical incision required an An intermediate/advanced workshop. Using code for a complex procedure when a routine medical service was performed. For instance, +22845. Alternatively, upcoding also includes when a healthcare service provider indicates that a patient has a more serious diagnosis than they actually do, in order to increase the reimbursement rate that insurance will pay. But, if the physician performs a medically necessary full neurological exam for the head trauma patient, then reporting a separate E/M with modifier 25 appended may be appropriate. All Rights Reserved. Whether procedures are performed separately or together might or might not determine the correct billing code. If the provider bills for each test separately rather than billing for the Unbundling comes in picture when multiple CPT codes are used to report components of parts of the procedure, either unintentionally or in order to increase payment. coding The HHS Office of Inspector General founds that from FY 2014 through FY 2019, the number of hospital stays billed at the highest severity level increased almost 20%. Unbundling also occurs when a coder charges for two services when the code for the major service assumes that the minor service is also provided. and private insurers to restructure their reimbursement models that stress A skilled coder will identify and assign the appropriate CPT and/or HCPCS Level II code(s) to correspond to each component of the overall service provided. NCCI edits bundle 66984 with 67036. Those who file qui tam lawsuits are protected under the provisions of the False Claims Act that prohibit retaliation against whistleblowers, such as being discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment.. Last month, EyeNet provided an overview of the National Correct Coding Initiative (NCCI), explaining that CMS lists pairs of services that should not be billed together when performed by the same provider on the same patient on the same day. Unbundling is billing for procedures separately that are normally covered by a single, comprehensive CPT code. For team surgeons using modifier 66, the Global Surgery Booklet advises that claims must have enough information to allow the MAC to determine pricing by report. For assistant-at-surgery services by physicians, the Medicare rate is 16% of the surgical payment. Insurance Verification and Authorizations, Fragmenting one service into component parts and coding each component part as a separate service, Reporting separate codes for related services when one comprehensive code includes all related services, Breaking out bilateral procedures when one code is appropriate, Separating a surgical approach from a major surgical service. Double billing also happens when providers bill for the same procedure first using an individual code and then as a bundled code. While each of these modifiers is important, a few deserve special attention because theyre among the most used (or misused). An example of unbundling is billing parts of a single, whole procedure separately. If a hospital were to bill for the incision and stitches performed during a surgery as separate procedures, this would be an example of unbundling., Another example would be blood work. Our vision for the providers is You Cure. Thats because the guidelines for Medicaid billing depend on the state, so the claim submission formalities also, Keeping your facility in compliance with HIPAAs regulations is crucial for any Florida medical practice. To NCCI is continually working towards to prevent wrong coding and fraudulent claims. Access: Academy Plus course pass required. When medical billing services charge a patient separately for procedures that can be bundled in one, then it is Enjoy hands-on ICD-10 training. In 2017, nearly $3.4 billion of the $3.7 billion recovered by the government under the FCA was the result of cases reported by whistleblowers. What is Unbundling in Medical Billing? Americans spent over $3.5 trillion on healthcare in 2017, and fraudulent medical billing practices may account for as much as 3% of that spending, according to the National Healthcare Anti-Fraud Association. The MULT PROC (Multiple Procedure) column in the Medicare relative value files is connected to modifier 51 Multiple procedures. Claims that do not have the pricing modifier in the first position may encounter processing delays. We represent clients nationwide with offices in Birmingham, AL, Tallahassee, FL and Albany, GA. Billings to Medicare and Medicaid must use the HCPCS. Pro-fee coders may consider appending modifier 52 Reduced services or modifier 53 Discontinued procedure to a medical code when a provider does not complete the full procedure or service described by that code. Coding SOS. These modifiers belong after pricing modifiers on the claim. This occurs when a provider intentionally bills Medicare/Medicaid and a private insurance company or patient for the same treatment. Medicares Global Surgery Booklet provides these examples: The TEAM SURG (Team Surgery) column is connected to modifier 66 Surgical team. Exam Prep - Chapter 5 - Compliance about a potential case to Phillips & Cohen LLP, we do not become your attorneys. EndoGastrics device could be implanted through two procedures, one more invasive and more expensive than the other. Examples featuring indicator 1. Those inpatient stays cost Medicare $54.6 billion that year. Therefore, the code with the highest allowablein this case, vitrectomy should be listed first. The FCA also protects whistleblowers from the risk of employer retaliation. Billing a telehealth patient for an office visit. In addition, the defaulting medical practice may be permanently excluded from participating in Medicare and Medicaid. When youre reporting an E/M code representing the decision to perform a major surgery (one with a 090 global indicator, which represents a 90-day global period), you should append modifier 57 Decision for surgery, and not modifier 25. To avoid the medical coding mistake of unbundling, here is what you need to do: When decision-making for the procedure or test is done on an office visit, dont bill another E/M when the patient comes back for the test/ procedure. assigning 0 ir 9 as the 4th or 5th digit instead of reviewing the coding manual for the appropriate code. Unbundling is a form of medical billing fraud that is similar to upcoding. WebWhen a doctor bills for each service individually, even though Centers for Medicare and Medicaid Services (CMS) has assigned a code to the services as a group, he is unbundling. She brings twenty five years of hands on management experience to the company. Explore TEPEZZA (teprotumumab-trbw) nowfor your patients with this serious, progressive disease. However, staying within the regulations is often easier said than, Subscribe for actionable tips and insights to grow your medical practice >. Two prevalent and increasingly common methods of perpetrating billing fraud are known as Upcoding and Unbundling.. The same patient then has a left-eye cataract extraction (again, 66984) by the same physician during the global period for the first procedure. NCCI edits are used to review claims prior to payment. When two procedures should be bundled in a single CPT code, coders who bill the two procedures separately using two CPT codes are unbundling the procedures. For example, doctors may use a code to indicate that they performed a complex procedure, when they only performed a routine one. Studies of medical billing fraud make it clear that upcoding fraud and unbundling fraud dont happen in a vacuum. WebExamples of Unbundling Fraud Unbundling Lab Tests Medicare and Medicaid have found it difficult to reign in the unbundling of lab tests. Looking to save time and money on your medical billing? In other words, it will take hard work. Here are six medical coding errors and how to prevent them in your practice. What do these three pairs of procedures have in common: pterygium excision and cataract surgery; visual fields and blepharoplasty; and gonioscopy and argon/selective laser trabeculoplasty (ALT/SLT)? In their bundling guidelines, Blue Cross Blue Shield of North Carolina lists services considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance, which are not eligible for separate reimbursement: According to the AAPC, a clear understanding of the differences between the rules pertaining to coding, billing, and reimbursement is necessary to know when unbundling can turn potentially problematic. As per existing medical billing guidelines, you cannot fragment a service into parts and code each component separately. When considering whether to append modifier 59, medical coders must factor in the so-called X{EPSU} modifiers mentioned above. According to Healthcare Business and Technology, doctors lose $125 billion each year because of poor medical billing systems and errors. The whistleblower in this case received $17,225,000 as a result of the governments favorable settlement. For instance, Medicare states you should use modifier JW only with drugs designated as single use or single dose on the FDA-approved label or package insert. When: From Sunday, Nov. 11, to Tuesday, Nov. 13. The NCCI table shows that CPT code 15823 Blepharoplasty, upper eyelid; with excessive skin became bundled with CPT codes 92081 Visual fields exam; limited and 92082 Visual fields exam; intermediate on Jan. 1, 1996, and Jan. 1, 1998, respectively.