Modifier use without supporting documentation could be considered fraudulent, write Ray Painter, MD, and Mark Painter.
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.
Questions to consider
The base concept of the intraoperative surgical package includes all necessary aspects of the procedure or service as described by the CPT definition. We have summarized this concept by asking the following two general questions:
Was the service provided required for the billed service? Examples include:
• Was a laparotomy required to remove the lymph nodes that were sent for frozen section during an open lymphadenectomy?
• Was lysis of adhesions required to safely and adequately remove the kidney?
• Was visualizing the entire bladder to make sure all the bladder tumors were resected expected medical practice?
Is there a CPT code that describes everything we did for the patient? Examples include:
• Is there a code that includes radical nephrectomy and removal of thrombus from vena cava?
• Does the code indicate that it should be reported for each tumor removed?
If the answer to either or both of these questions is yes for a majority of cases and providers, then all the services should be considered as bundled into the appropriate code or codes selected and no additional codes should be reported.
We encourage you all to be diligent, accurate, and honest in answering these questions. Over the years, we have seen many examples of missing this concept in over- and under-reporting. A few examples include:
• not reporting prostatectomy with a cystectomy
• reporting urethropexy with robotic prostatectomy for simple closure and repair after removal of prostate
• reporting vaginoplasty with cystocele repair for simple closure of vaginal wall.
Medicare and other payers are charged with paying only for those services that are medically reasonable and necessary. We are all aware of the restrictions placed on appropriate billing circumstances, including local coverage determinations and prior authorizations (subjects of other articles). For rules surrounding bundling/unbundling, the payers have taken this general concept to the point of being obsessed with the idea that physicians should not be paid twice for any service provided. Therefore, if under any circumstance, one procedure overlaps or duplicates services being paid for by paying for a primary procedure at the same encounter, the procedure is bundled by rule.
The CCI and the private payer datasets have been developed with a combination of interpreting the CPT code manuals and descriptions and a review of billing patterns. The datasets are all based on the average case and/or the volume of services billed in conjunction with other services. The combination of these two approaches has led to many bundling pairs that are either generally inaccurate or not applicable to all circumstances. As an accommodation to these acknowledged shortfalls, the database includes situational accommodation, and modifiers have been added to allow for appropriate reporting of these circumstances when appropriate.
For the published Medicare CCI, if a coded service is considered to always be a part of a second procedure/service (two procedures that overlap in services), the bundling edits will read “unbundling never allowed.” However, if it is determined that under certain circumstances, performing the procedure does not duplicate services performed in the primary procedure (two procedures with no overlap of services), the bundling edits will read “unbundling allowed w/ modifier.” Private payer datasets also contain these accommodations but may not be published or easily identified without direct challenge through billing.
In order to consider reporting two services that pass the concept test above, you will need to document both the details of the procedure (to prove that you performed the procedure) and the reason for performing the procedure (to prove medical necessity). (What’s obvious to you may not be obvious to the reviewer hired by the payer.) If the rest of the billing is handed off to the billing department, the “circumstances” for that particular encounter should be conveyed as well.
If a second procedure was performed for a different reason or circumstance, then you need to communicate the reason so the billing department will understand the appropriate way to bill in order to ensure you are paid for that service.
As it is difficult to remember which codes are a part of the bundling rules and which are not part of the rule set, it is important to establish a process to determine when a modifier should be added and which one. It is recommended the codes selected for reporting the service are double checked to be sure they are correct and complete and the appropriate documentation is included. The next step will be to check the bundling edits using a database such as AUACodingToday or the payer website if available. Most people find the “Bundling Matrix” included in AUACodingToday to be the easiest and fastest way to check.
If the codes are bundled by rule, the use of a modifier will be required. If the codes are not bundled by rule, the services can be reported on separate claim lines using –51 for lower valued procedures for non-Medicare payers, which routinely incorrectly pay for the services billed.
Next: Choose the correct modifier
Choose the correct modifier
Some payers may require the CPT modifier –59 for the majority of these cases. A list of the payers that require the more specific –X (E, S, P, U) modifiers should be kept and referenced. The definitions of the –X modifiers are as follows:
• XE: Separate encounter
• XS: Separate structure/organ
• XP: Separate practitioner
• XU: Unusual non-overlapping services.
In some cases, it may be more appropriate to use a location modifier in place of modifier –59 or one of the –X modifiers. Location modifiers such as –LT and –RT are designed to communicate that a procedure, considered bundled if provided on the same side, was actually provided on the contralateral side during the same operative session. An example would a stent insertion on the right side during the same session as a lithotripsy and stent insertion on the left side. Proper coding for this situation would be 52356 –LT and 52332 –RT. As location modifiers provide more specificity than the other modifiers, it is recommended that these modifiers be used to report bundled procedures if applicable. (Note: –RT and –LT should not be reported if the same procedure is provided on both sides of the body; instead, modifier –50 should be appended to the code indicating the same procedure was provided on separate sides of the body at the same session.
Accuracy is key. Never routinely add modifiers to unbundle procedures just because they’re bundled. This, unfortunately, is the routine for many billers.
As you can see, there are many opportunities for lost revenue or inappropriate billing. Start with the documentation. Merely saying the procedure was performed is not adequate. You must document the details of the service performed if you expect to get paid. Probably the biggest mistake we see is inadequate communication between the provider and the billers. Start at the beginning and make sure that you and your billing team are on the same page. Follow selected patient claims through the billing process to make sure that everyone is on the same page. Finally, get some feedback from your billing support team.
A little time is worth a lot in terms of peace of mind, and the resulting return on investment will be obvious.
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.