What is “bundling” anyway? This is when an insurance carrier combines two or more CPT codes, replacing an overreaching code, often ignoring modifiers along the way. This practice can cut your receivables. When codes are bundled, the codes are grouped together and the insurance carrier will only pay a fee schedule allowance for the codes they find appropriate.
There are ways to get around bundling. First you need to make sure that you are properly billing the claim upon initial submission. For example, if you are billing for an E&M code for a patient who comes with high blood pressure, but the patient is complaining of knee pain and you are having an aspiration for the knee joint. , Then you need to make sure that you use the correct modifier to indicate what you are doing. You want to bill the E&M code, saying it is 99213, with 25 modifiers indicating that it is a separate and distinct service provided during a single visit. You will then bill for aspiration of the knee joint with the appropriate code using 59 modifiers to indicate a different procedural service.
To get full reimbursement for your services it is very important to know the proper use of all the various modifiers. Also important as this is the ability to read an EOB (Explanation of Benefit Statement) correctly. EOBs can be quite complex and it is important to understand what the insurance company did with the claim.
When the claim is processed and you receive an EOB you need to make sure that the insurance company has allowed both codes separately. Eventually, you visited an office to manage high blood pressure and you aspired which was completely different from an office visit.
If the insurance carrier bundles your code then you should file an appeal. If you go through the appeal process, in many cases the insurance carrier will re-submit the claim and remove the codes.
The appeal does not have to be complicated. This can be a form letter that you design where you need to fill in the blanks. Too many carriers bundle claims upon initial processing because most offices will not appeal the claim. Just imagine how much money they save!
You may think that it is not worth the time to appeal but you may be surprised if you know how much money you have actually lost over time. If you have a system for filing appeals which is a fairly simple process then it will not take long and you can increase your receipt. In my opinion, it is worth the effort.
Copyright 2007 – Michelle Redmond