Procedural coding: How to make the process work


Procedural coding: How to make the process work

There are two main sets of rules to know in order to be appropriately paid for procedures, and, according to the rules, anything from a 10000 CPT code through the 69999 CPT codes are procedures. Obviously, this includes all urologic surgical procedures in the 50000 series. This is an area in which the physician has to be knowledgeable in order to:

Bundling vs. global rules

There are two sets of rules that must be understood in order to bill accurately for surgical procedures: bundling rules and global payment rules. The rules are totally separate, and the modifiers used are different.

Bundling, in theory, is the process of including all integral parts or components of a procedure in the payment for a single CPT code. Bundling applies only to a single patient episode of care.

"Global" is the process of a packaging the preoperative care, the surgery, and the postoperative care for a defined period of time into a single payment. Global payment rules will be discussed in a future article.

In billing, unfortunately, the two sets of rules overlap in some situations. When you bill for a service, a computer determines how to pay you, and computers are not programmed for episodes of care. They are programmed to pay based on a "calendar day." Therefore, the computer will apply the bundling rules to all services provided on the same calendar day.

The concept of bundled procedures is a valid one. If you are being paid to perform a radical cystectomy, you should not be paid for the opening and closing of the wound, mobilization of the bladder, removal of the distal ureters, etc. However, if during the same operation, you performed another, unrelated surgical procedure, you should be paid. Because it is not possible to program a computer for an episode of care, the bundling rules are applied to all patient services provided on the same date, even if they are provided at another patient encounter.

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