Archive September 2000 I, No. 9

How to Avoid Unbundling

Lolita Jones, RHIA, CCS

BIO

Could you explain Medicare's Correct Coding Initiative (CCI) edits and how they may apply to our Medicare claims?

A.

Medicare developed Correct Coding Initiative (CCI) edits to prevent providers from fragmenting or "unbundling" when coding and billing for Medicare services. Unbundling means improperly coding the component parts of a procedure instead of reporting a single code that includes the entire procedure. In some cases, unbundling may occur because the coder simply misunderstands the proper coding process. There have been cases, however, when healthcare providers intentionally manipulated coding to maximize payment; this constitutes Medicare fraud.

Following are some examples of unbundling: Fragmenting one service into component parts and coding each component part as if it were 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. One possible example of this might be reporting a laparoscopic hernia repair using two codes – one for a diagnostic laparoscopy and another for the laparoscopic hernia repair. In this example, including the diagnostic laparoscopy code would be incorrect; the laparoscopic approach is already included in the laparoscopic hernia repair code.

Case Study: A Medicare patient undergoes a ureteroscopic fulguration of a lesion with cystoscopic replacement of a ureteral stent. You have tentatively assigned codes:
- 52338 (cystoscopy, ureteroscopy with biopsy/fulguration lesion),
- 52310-59 (cystoscopy with removal of ureteral stent)-distinct procedural service, and
- 52332 (cystoscopy with insertion of indwelling ureteral stent).

Before billing the claim, you reference the current version of the Medicare CCI edits (see table) to find that:
- code 52338 is not a "Component Code" for 52310 or 52332,
- code 52310 is not a "Component Code" for 52338 or 52332, however,
- code 52332 is a "Component Code" for 52338; in other words, it is an integral component of code 52338. Therefore, you cannot report code 52332 on the claim form for the case. The final codes that you would report to Medicare would be 52338 and 52310-59.

If you mistakenly bill Medicare for the procedure in both the "Comprehensive Codes" column and the "Component Codes" column for the same beneficiary on the same date of service, Medicare will only reimburse you for the "Comprehensive Codes" column code.

The policies developed in the Correct Coding Initiative are based on:

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coding conventions defined in the AMA's CPT manual;

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national and local policies and edits;

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coding guidelines developed by national societies;

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analysis of standard medical and surgical practice; and

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review of current coding practice.

The CCI edits are updated every January, April, July, and October. For more information about them, contact your Medicare Fiscal Intermediary, Carrier or the National Technical Information Service (NTIS) in Springfield, Virginia, at (800) 553-6847.

One note to freestanding ambulatory surgery centers: Medicare's Correct Coding Initiative instructions also apply to claims for ASC facility services (see the Medicare Carrier's Manual, Part 3, Section 4630 Correct Coding Initiative, Subsection K. Ambulatory Surgical Center (ASC) Facility). However, in order for Medicare to reimburse the facility for an approved code under CCI, it must also be on the list of Medicare-covered ASC procedures.

In some cases, you may be able to use modifiers to properly code for multiple procedures and avoid the unbundling trap. For example, you could use modifier –59, the distinct procedural service modifier, to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. Modifier -59 may represent, for example, a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same physician.

Following are some other common modifiers:
- eyelid modifiers (E1 – E4)
- toe modifiers (TA – T9)
- finger modifiers (FA – F9)
- left side modifier (-LT)
- right side modifier (-RT)

If you use these modifiers correctly, you can report a separate code and charge for each procedure. Medicare will base payment on 100 percent of the group rate for the highest paying procedure and 50 percent of the group rate for the second procedure, less applicable deductibles and coinsurance.

Always maintain hard copies or electronic copies of each quarterly version of the CCI edits. The edits that you applied for a case performed in January 1999 may be different for the same case performed in September 2000. If you are audited for a case that was coded several years back, you may need to refer the auditors to the CCI edits that were in effect at that time.

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