Ever submitted a seemingly perfect medical claim, only to have it denied for unbundling? It’s a frustrating scenario, leaving you wondering where the error lies. Unbundling in medical billing happens when you bill for individual components of a service, rather than using a single comprehensive code. This can lead to claim denials, delays, and ultimately, lost revenue for your practice.
This blog post aims to equip you with the knowledge to avoid unbundling and ensure your claims get processed smoothly. We’ll break down the concept, explore the pitfalls, and offer practical tips to keep your billing accurate.
Understanding Unbundling and the Role of CMS
Unbundling can be unintentional or deliberate. In most cases, it’s an honest mistake arising from a lack of awareness about comprehensive codes. The Centers for Medicare & Medicaid Services (CMS) play a crucial role in preventing unbundling by establishing coding guidelines and the National Correct Coding Initiative (NCCI) edits. These edits act as a reference point, specifying which code combinations are improper for billing together.
For example, imagine a patient receives a comprehensive metabolic panel that analyzes various blood components like glucose, cholesterol, and electrolytes. Billing each test individually would be considered unbundling. Here’s a breakdown of why this is wrong:
- Inaccurate Representation of Service: Billing each test separately misrepresents the service provided. The comprehensive metabolic panel is a single service that analyzes a group of related components.
- CMS Guidelines: CMS establishes specific codes for comprehensive services like metabolic panels. Billing individual codes goes against these established guidelines and can lead to claim denials.
Essential Tips to Prevent Unbundling Errors
Here are some key strategies to keep your billing on track and avoid unbundling:
- Embrace Comprehensive Codes: Always search for all-encompassing codes that reflect the complete service rendered. Medical billing software often suggests appropriate codes based on the documentation, but a double-check is crucial. Here’s how to effectively utilize comprehensive codes:
- Review Documentation: Before selecting codes, thoroughly review the physician’s notes to understand the exact service provided.
- Search for Encompassing Codes: Utilize your medical billing software’s search function to find comprehensive codes that accurately describe the service. Many software programs offer helpful filters based on the type of service or body system involved.
- Double-Check the Code Description: Once you’ve identified a potential comprehensive code, don’t just rely on the code itself. Read the official description to ensure it aligns perfectly with the service provided.
- Befriend the NCCI Edits: Familiarize yourself with the NCCI edits published by CMS. These edits list pairs of codes (Column One and Column Two) that shouldn’t be billed together because they represent the same procedure, like a chest X-ray (Column One) and a lung X-ray (Column Two). Understanding these edits can significantly reduce claim denials due to unbundling. Here’s a deeper look at how NCCI edits work:
- Column One and Two: The edits categorize codes into two columns. Column One typically represents the main procedure, while Column Two includes procedures considered inherent or bundled within the main procedure.
- Identifying Improper Combinations: By reviewing the NCCI edits list, you can identify code combinations that are flagged for improper billing. For instance, if you see “chest X-ray” in Column One and “lung X-ray” in Column Two, you’ll know these shouldn’t be billed separately.
- Staying Updated: NCCI edits are updated regularly. Subscribing to updates from CMS ensures you have the latest information to avoid billing errors.
- Regular Claim Review: Make claim review a standard practice in your billing workflow. Double-check that the codes billed accurately reflect the services provided and don’t overlap. This helps identify potential unbundling issues before claims are submitted. Here’s how to make claim review effective:
- Compare Codes and Documentation: Cross-reference the billed codes with the physician’s notes to ensure they accurately represent the service. Look for any discrepancies or missing information.
- Check for Overlapping Codes: Review the codes for potential overlaps. For example, if you’ve already billed a comprehensive metabolic panel code, ensure you’re not also billing individual codes for tests included in the panel.
- Consider Utilizing Claim Review Software: Several software programs offer automated claim review functionalities. These can help identify potential coding errors and unbundling issues before submission.
When to Seek Professional Help
Medical coding can be intricate, and even with these tips, unintentional mistakes can occur. If you’re dealing with complex procedures or a high volume of claims, consider partnering with a reliable medical billing and coding service like expEDIum. Our team of certified coders stays up-to-date on the latest coding regulations and utilizes advanced tools to ensure accurate and compliant claim submissions.
By following these steps and seeking expert help when needed, you can ensure your billing practices are on point. This not only reduces the risk of unbundling and claim denials but also streamlines your revenue cycle and frees up your staff to focus on patient care. Let expEDIum help you navigate the world of medical coding. Contact us today to discuss your needs!
