As we travel the country, we have been impressed by the great questions we are asked, which demonstrate a very respectable knowledge of the Correct Coding Initiative (CCI). On the other side of the coin, we have been shown numerous rejections/denials that show a very apparent lack of understanding of CCI. Questions regarding modifier –59 and the CCI are those that are truly pushing the envelope for a few dollars more. The bottom line is that we see too many mistakes in billing for bundled or potentially bundled services.
What constitutes ‘unbundling?’
Billing for procedures that are “bundled” by adding the appropriate modifier to the lesser procedure—usually –59 for private payers or one of the four “–X” modifiers for Medicare—is considered unbundling. Billing for services that are not bundled but are in fact included as a part of the approach or part of the standard performance of the procedure is also considered unbundling. Unbundling is justified, legal, and should be utilized in many situations.
Unfortunately, there are also many situations in which you should not bill for the secondary procedure. In fact, if a modifier is added in the absence of documentation that supports the use of the modifier, its use would be considered abusive and if repeated could be considered fraudulent and certainly could lead to “take-backs” or possibly penalties. Similarly, unbundling just because the CCI allows the codes to be reported together will result in payment that is also ripe for take-backs and/or penalties.
The problem of navigating these bundling/unbundling rules is somewhat like a busy and confusing traffic circle. Questions about when to get in, when to add modifiers (change lanes), and which modifier to use (how to get out of the circle) all must be addressed. Understanding when to bill or not to bill and how to bill will help you choose how to get out of this coding traffic circle with the best results.
The concepts behind bundling
In order to make the correct decision every time, one needs to understand the two concepts related to reasons for bundling in the first place. The first and overarching concept of bundling/unbundling goes back to the idea of the global surgical package. The global concept actually starts with the CPT in reference to the global surgical package for each code. Although the global surgical package applies to preoperative, intraoperative, and postoperative care, for this article we will focus only on the global concept of intraoperative care.
Second, you must understand the rules surrounding the concept. With any general concept, there is likely to be an added interpretation or a refinement into a set of rules. Medicare, private payers, and organized medicine have all provided further interpretation of what a global package should include. Computers, and the programs developed to interpret the global concept, are a further refinement of these rules. The CCI and similar private sector coding databases represent the growing set of rules implemented to further define the concept of the same-day global package concept. The rules are not always fair and at times make absolutely no sense.