Medicare Compliance & Reimbursement - 2019 Issue 8
Reader Question: Question Payer Policy in This E/M Bundle
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Article Overview
This reader Q&A discusses a payer denial involving an evaluation and management service and a urinalysis claim, with emphasis on general bundling concerns, payer-specific edits, and how coding professionals may approach documentation review and carrier communication. It is useful for billers, coders, and practice staff who handle office visit claims, laboratory service edits, and claim adjudication issues.
Why This Topic Matters
Denials based on bundling can affect reimbursement and create repeat claim issues, so understanding whether a payer edit is national or payer-specific helps teams respond appropriately and resolve claim processing problems.
Article Sections
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Question
A billing scenario is presented involving a denied outpatient visit claim and a laboratory service. The issue centers on whether the services were treated as separately payable or bundled.
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Answer
The response discusses the absence of a national edit for the services in question and suggests payer follow-up, documentation support, and possible claim resubmission approaches. It also references a modifier commonly associated with separate procedural reporting.
What You Will Learn
- How payer bundling denials may differ from national coding edits
- What general steps are discussed for addressing a claim denial with a carrier
- Why documentation and carrier communication can matter in edit resolution
- How article guidance frames separate reporting of an office visit and laboratory service
Who Should Read This
- Medical coders
- Billers
- Revenue cycle staff
- Physician office staff
- Compliance and coding auditors
Codes Discussed
Modifiers Discussed
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