Bundling is defined as the inclusive grouping of codes related to a procedure when reporting and submitting codes to the payer for medical services rendered. Some codes, by nature, are included in other codes that describe a more comprehensive service, which encompasses the lesser procedure. In reimbursement systems the more comprehensive code is valued at a rate that includes the lesser procedure, so it becomes inappropriate to report both codes. Reporting multiple CPT or HCPCS codes when a single comprehensive code describes the service(s) provided is referred to as “unbundling.”
The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to prevent improper coding and reporting of procedures or services that should not be reported together. The NCCI which consist of Column 1 and Column 2 correct coding edits identifies code pairs that should not be billed together for several reasons, including situations where one service/procedure is considered an integral part of the other.
Initially, the NCCI was identified by two types of bundling edits, which were Comprehensive/Component Edits and Mutually Exclusive Edits. These edits identified code pairs that should not be reported together for reasons outlined in the NCCI Coding Policy Manual for Medicare Services. Consolidation of the files into Column 1 and Column 2 Correct Coding edits by CMS simplified their use. These edits are now referred to as NCCI Procedure-To-Procedure (PTP) edits.
The NCCI PTP edits prevent payment for services, which are components of a more comprehensive procedure.
For example, a patient has a stress test performed and the coder reports CPT code 93017, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report, for the stress test, and CPT code 93005, Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report, for the EKG.
However, because the EKG reports what is happening during the stress test, the EKG is considered an integral component of the stress test and would not be reported in addition to the stress test.
CPT’s designation of “separate procedure”
There are a few procedures that are commonly carried out as an integral part of a total service or procedure, but on occasion these procedures may be performed independently. In the CPT codebook these procedures are identified by the inclusion of the words ‘separate procedure” within the code descriptor. Codes with this designation are considered inclusive and should not be reported in addition to codes for the primary procedure or service.
According to NCCI, these two codes may only be reported together with the appropriate modifier when they are performed in separate anatomic regions or through separate anatomic approaches.
Procedures should be reported with the most comprehensive CPT code that describe the services performed. Reporting codes separately for services/procedures described in a single comprehensive CPT or HCPCS code is known as “unbundling”. Unbundling is considered an incorrect and inappropriate coding practice. Here are a few incorrect/inappropriate coding practices to be avoided.
- Multiple HCPCS/CPT codes should not be reported when a single comprehensive HCPCS/CPT code describes the service(s) provided.
- HCPCS/CPT code should not be fragmented into component parts.
- Do not unbundle a bilateral procedure code into two unilateral procedure codes.
- Do not unbundle services that are integral to a more comprehensive procedure.
It is the coder’s responsibility to assign all components of a service/procedure without fragmenting the service/procedure into component parts and “unbundling” when reporting services provided for an encounter that can be captured in a single code assignment.
For example, a patient undergoes an anal endoscopy with biopsy, the coder should report CPT code 46606, Anoscopy; with biopsy, single or multiple. It would be incorrect to unbundle this procedure and report CPT code 46600, Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure), plus CPT code 45100, Biopsy of anorectal wall, anal approach (e.g., congenitial megacolon), since the biopsy is included in CPT code 46606.
In another example, reporting CPT codes 58150, Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); 58700, Salpingectomy, complete or partial, unilateral or bilateral (separate procedure), and 58940, Oophorectomy, partial or total, unilateral or bilateral; for a total abdominal hysterectomy with removal of tubes and ovaries. In this example, CPT code 58150 includes all three procedures performed. Therefore, it would be incorrect to unbundle these services, which are integral to the more comprehensive procedure code. Although there are many instances when some services/procedures may be reported separately coders must be aware of when it is allowable and when it is not. Many problems arise when bundled services/procedures are inappropriately reported separately.
Let’s take a look at a few bundling basics to remember:
- Closure of a surgical opening is considered an integral part of the surgery and not separately reported.
- A diagnostic endoscopy would not be separately reported when performed in conjunction with a surgical endoscopy.
- It is unacceptable to unbundle procedures into separate codes when a combination or comprehensive code is available for reporting.
- NCCI PTP edits exist where CMS expects that 2 codes would not be routinely reported together. For this reason, coders should not routinely use modifiers to bypass edits but should only apply modifiers such as the -59 modifier when a specific clinical situation exists that renders the usual edit inapplicable. Coders, revenue cycle staff, should be especially careful if they find they are using the -59 modifier frequently.
- When in doubt, always check the NCCI Procedure-To-Procedure edits which can be located at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html