The goal of the NCCI is to prevent fraud and promote accurate coding. The table also shows that CMS deleted the edit for CPT codes 66821 YAG and 66761 Iridotomy. When medical billing services charge a patient separately for procedures that can be bundled in one, then it is You and your staff work hard to deliver your patients the best possible medical care. However, stitches are sometimes performed as a separate procedure, such as when a patient comes into the hospital with a pre-existing wound. Insurance companies and the administrators of government programs (like Medicare and Medicaid) rely on the codes as a standardized description of the services and procedures for which the medical practice seeks payment. WebUnbundling. By comparing medical records to medical billings, a medical billing expert can determine whether separately coded procedures were performed at the same time. The use of electronic health records (EHR) software can facilitate upcoding and unbundling. Modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period is appropriate for use only on E/M codes and only for services unrelated to the original procedure (the one with the global period). WebThe following are examples of healthcare fraud which you may encounter and should report: Misrepresentation of the type or level of service provided; Misrepresentation of the individual rendering service; Billing for items and services that have not been rendered; Billing for services that have not been properly documented; Unbundled charges will generally need to be bundled to produce a reasonable bill. All Part B Medicare claims are processed in this way. When the patient returns to the operating or procedure room during the global period for an unplanned but related procedure, you should append modifier 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period. 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. You enter the pricing modifier directly to the right of the procedure code on the claim. One lesion is excised and another is biopsied, both on the right lower lid. The codes used by HCPCS were developed by the Centers for Medicare and Medicaid. Essential Coding Rules Everyone Needs 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. An Advance Beneficiary Notice of Noncoverage (ABN) form helps a beneficiary decide whether to get an item or service that Medicare may not cover. Is CPT coding hard? However, if the repair was done on a different site from where the lesion was removed, both procedures can be billed and a modifier can be appended to let the payer know the skin repair was separate from the excision. The manual also states you may append modifier 25 to an E/M code performed on the same date as a code with a global indicator of XXX. The legal issues surrounding whistleblower protections are complicated, and obtaining relief for discharge, demotion, or discrimination as a result of whistleblowing involves knowing how to navigate relevant federal and state laws. The work and time related to suture removal and routine post-biopsy care are not separately reportable, but you can report the E/M service using modifier 24. The rules for the reimbursement of multiple procedures mean payment for the code that is listed first will be 100 percent of its allowable; for the code listed second, 50 percent of its allowable. WebThe remaining selections are all examples of unbundling and therefore, would not be appropriate in this scenario.) However, this improper billing can take many different forms, making it more difficult to identify. Read theseexamples of upcoding and unbundling multi-million dollar penalties shared by Phillips and Cohen( an international law firm). Upcoding refers to the practice of using an inaccurate billing code to obtain a higher reimbursement for a medical treatment or procedure. If you are aware of any illegal medical billing practices, contact a medical billing fraud attorney today for a confidential, free consultation. The Centers for Medicare and Medicaid (CMS) publishes National Correct Coding Initiative (NCCI) edits, which are pairs of codes that should not be billed together. PracticeForces has served U.S. providers, solo medical practices, and multi-practice group owners since 2003. Immediate surgery is scheduled. The policy applies to work performed by same-specialty members of the same group. Correct coding: CPT code 66984RT (for the cataract removal) and CPT code 6682159LT (for the Nd:YAG). Unbundling Fraud: Case Examples | Whistleblower Lawyer Atlanta This includes healthcare providers reimbursed through government healthcare programs like Medicare and Medicaid. Note that CPT code books often include an abbreviated list of HCPCS Level II modifiers. Upcoding and Unbundling Charges in Medical Billing Double billing also happens when providers bill for the same procedure first using an individual code and then as a bundled code. Test us for free with a no obligation free trial. Modifier 77 Repeat procedure by another physician or other qualified health care professional is appropriate to use when a different provider repeats a procedure or service subsequent to the original procedure or service. Diagnostic nasal endoscopies are another example. Use of modifiers. Determining whether an E/M service occurred on the same date of service as another procedure or service is typically straightforward. The AMAs CPT codes are incorporated into the Healthcare Common Procedure Coding System (HCPCS) codes required for Medicare and Medicaid billing. Unbundlingbilling separately for multiple components of a procedure that should be billed as a single charge. Ensure that your medical coding staff refers to the latest version of the National Correct Coding Initiative (NCCI) edits published by CMS. All are subject to National Correct Coding Initiative (NCCI) edits. 4. Duke settled the lawsuit for $1 million. 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. Modifier 79 should be used to indicate that cataract removal and vitrectomy are unrelated to the pterygium surgery. Bundling/Unbundling Medical Procedures. Although the complications billed suggest sicker beneficiaries, the shorter lengths of stay point to beneficiaries who are less sick, the OIG said. A basic CPT code is a five-digit code that describes the precise procedure or service that doctors provide to their patients. Unbundling is also known as fragmentation, i.e, the provider is taking a medical procedure that could be billed with one code and fragmenting it into multiple codes, to add up to a higher reimbursement. You should not report an E/M code for that work, even with modifier 25 appended. ABN claim reporting modifiers are listed in the MLN booklet Medicare Advance Written Notices of Noncoverage with the following explanations: Modifier GA Waiver of liability statement issued as required by payer policy, individual case, Modifier GX Notice of liability issued, voluntary under payer policy, Modifier GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit, Modifier GZ Item or service expected to be denied as not reasonable and necessary.