THE EOB SAYS “BUNDLED” - NOW WHAT?

by  Marge McQuade CMSCS, CHCI, CPOM
December 12th, 2017

Payers often bundle separate codes together so that they can pay you less. Just because the EOB says the codes are bundled doesn’t mean you have to let the insurance company get away with it. Fight Back!!!

How does bundling work?  If a patient presents for evaluation of diabetes, and the doctor notices two suspicious skin lesions—one on the neck and one on the back and he decides to biopsy one and excise the other. You code: 99213 with modifier –25 (E&M for evaluation of diabetes); 11402 (back lesion excision, benign, 2.0 cm); 11100 with modifier –59 (biopsy of neck lesion).

Modifier –25 is for a separate and distinct service provided during the same visit. Without modifier –25 on the E&M 99213, both lesion codes might be denied, or the E&M code itself might be denied. The modifier tells the payer that the codes are truly separate.

Modifier –59 is for a distinct procedural service. It should alert the payer that two services that normally would be bundled into the lesion code should be paid separately because you performed the biopsy (11100) separately. The two lesions were truly distinct, separate, and unrelated to each other.

If the insurer ignores modifiers –25 and –59, and does not recognize each separate service for payment, that means it's bundling the codes.

The only way to combat bundling by the insurance companies and get the reimbursements you're entitled to is to track your claims and check them against your explanation of benefits when they arrive. When your EOBs come in, look for coding changes and reimbursements that don't match your contract or what was billed.

When examining EOB’s watch for these red flags:

• When the EOB omits bundled codes as though the service were never provided. For example, you provided an E&M service and a minor surgery on the same day. You filed a claim using the –25 modifier, but when it came back, the EOB showed the surgery code alone, with no E&M code.
• When the code is listed, but the carrier omits the service modifier (such as –25 or –59), and there's no payment for the separate procedure.
• When a procedure code is listed, but there's no payment, because the carrier bundled the charge with an unrelated procedure for a different diagnosis. The EOB will usually note, "Payment for this service is included in the fee for the procedure."
• When an E&M procedure code is listed, but there's no payment, because the carrier bundled the charge with that of an unrelated surgical service.

These are all clues that an insurer may have improperly bundled services and they show up under the "remarks" column on the explanation of benefits form as:

• Payment for this service is included in the fee for the procedure.

• This service is a component of a primary procedure. Payment for the primary procedure includes reimbursement for the related procedure.

• Payment for one or more billed procedure codes has been denied because it is considered a component of this billed procedure code.

Some commercial insurers are notorious for systematic bundling. Challenge those companies by appealing, but make sure your appeal is within the deadline set forth in your contract. If it is an ongoing problem with certain insurers then register your complaint with the AMA, your state medical association and your state insurance commissioner. If you do not get satisfaction right away on your appeal, contact the plan's medical director or provider relations. As long as you have detailed documentation, your chances are good. But if your appeal is denied and you still feel that the insurance carrier bundled the charges erroneously, legal action may be in order.

Remember, as with all denials bundled or not, the best way to get the money your physician deserves is to fight for it and not take “no” for an answer from the insurance companies.  Checking your EOB’s against what you billed can bring “lost” revenue to the practice.