Are unbundling codes illegal?

Last Update: May 30, 2022

This is a question our experts keep getting from time to time. Now, we have got the complete detailed explanation and answer for everyone, who is interested!

Asked by: Dr. Joana White
Score: 4.3/5 (47 votes)

Upcoding & Unbundling are considered to be unethical billing practices. The Centers for Medicare & Medicaid Services (CMS) says that “[m]isusing codes on a claim, such as upcoding or unbundling codes” are unethical billing practices.

What would happen if a medical office is caught unbundling codes?

Unbundling or fragmenting billing codes illegally increases a provider's profits by billing bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid. The use of electronic health records (EHR) software can facilitate upcoding and unbundling.

What is an example of unbundling codes?

Unbundling (also known as fragmentation) is the billing of multiple procedure codes for a group of procedures normally covered by a single, comprehensive CPT code. An example of unbundling is billing parts of a single, whole procedure separately.

What does unbundling mean in coding?

Unbundling refers to using multiple CPT codes for the individual parts of the procedure, either due to misunderstanding or in an effort to increase payment.

Is medical Upcoding illegal?

Upcoding is illegal, but there are hospitals and healthcare providers who have been caught doing it. 4 Administrators who run healthcare systems can benefit professionally when their profits are impressive, and upcoding is one way to make that happen by cheating the system.

Ben Thompson explains the great unbundling | Code Media 2017

22 related questions found

Which is worse upcoding and Downcoding?

If the code that is recorded is for a higher level service or procedure than what is documented in the patient's chart, this is referred to as upcoding. Conversely, if the code that is documented is at a lower level of complexity or cost than what is documented, it is called downcoding.

What is a DRG creep?

1. Refers to the practices of healthcare providers that intentionally regroup patients according to more resource intensive DRG classifications in order to increase hospital income. Examples are 'upgrading' and 'upcoding'.

What is an unbundling modifier?

Modifier 59 Distinct procedural service is an “unbundling modifier.” When properly applied, it allows you to separately report—and to be reimbursed for—two or more procedures that normally would not be billed or paid independently during the same provider/patient encounter.

What is unbundling or fragmented billing?

Unbundling (also known as fragmentation) is the billing of multiple procedure codes for a group of procedures normally covered by a single, comprehensive CPT code. An example of unbundling is billing parts of a single, whole procedure separately.

What is modifier 25 in CPT coding?

The Current Procedural Terminology (CPT) definition of Modifier 25 is as follows: Modifier 25 – this Modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional.

What is a 24 modifier?

Modifier 24 is defined as an unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period. Medicare defines same physician as physicians in the same group practice who are of the same specialty.

How do you unbundle a code?

Using 59 is the only way to “unbundle,” which indicates to the payer that the two procedures were performed separately and the physician should be reimbursed for both of them. Yet coders frequently forget to add such appropriate modifiers to their CPT codes in instances like the one above.

How can we stop the Code of abuse?

6 Ways to Prevent Medical Billing Errors in Your Practice
  1. Keep up with medical billing and coding trends. ...
  2. Avoid duplicate billing. ...
  3. Be careful of inadvertent upcoding or undercoding. ...
  4. Make sure insurance has been verified. ...
  5. File medical claims within designated deadlines.

Is the Stark law?

Stark Law is a set of United States federal laws that prohibit physician self-referral, specifically a referral by a physician of a Medicare or Medicaid patient to an entity for the provision of designated health services ("DHS") if the physician (or an immediate family member) has a financial relationship with that ...

What is Undercoding?

Undercoding occurs when codes fail to capture all work performed. This is often due to oversight, but some practices intentionally undercode to avoid an audit. This is not recommended because it results in substantial lost revenue and creates skewed claims data that ultimately lower reimbursement rates.

What is bundling unbundling?

What Is 'Bundling and Unbundling'? Bundling means repurposing value that you already created to create even more value by combining multiple small offers into one large offer. ... Unbundling is the opposite of bundling, it means splitting an offer into multiple smaller offers.

Are all CPT codes 5 digits?

Each CPT code is five characters long, and may be numeric or alphanumeric, depending on which category the CPT code is in. ... Category III codes are temporary codes that describe emerging and experimental technologies, services, and procedures. Note that while CPT codes have five digits, there are not 99,000-plus codes.

What does the 51 modifier mean?

Modifier 51 Multiple Procedures indicates that multiple procedures were performed at the same session. It applies to: Different procedures performed at the same session. A single procedure performed multiple times at different sites. A single procedure performed multiple times at the same site.

What is the Xs modifier?

Modifier Code XS

This modifier is used to identify "separate structure, a service that is distinct because it was performed on a separate organ/structure".

What is a modifier 22 used for?

Modifier 22 — Increased Procedural Services: Add this modifier to a code when the work required to provide a service is substantially greater than typically required.

What is a cost outlier?

Cost outlier — an inpatient hospital discharge that is extraordinarily costly. ... To qualify for outlier payment, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments to qualify for outliers).

What factors affect case mix index?

It's important to remember, however, that this metric can be impacted by many different factors, including:
  • Coding accuracy.
  • Documentation specificity.
  • High volumes of highly weighted DRGs (like organ transplantations, cardiothoracic surgeries, or neurosurgeries)
  • Annual updates to relative MS-DRG weights.

What are some examples of financial uses of a case mix index?

The Case Mix Index has historically been used to calculate adjusted average cost per patient (or day) for a given hospital relative to the adjusted average cost for other hospitals by dividing the average cost per patient (or day) by the hospital's calculated CMI.

Why is down coding bad?

Downcoding may not be financially harmful to payers, but it does lead to the misallocation of funds. Downcoding is an unwise course of action that can backfire. For example, practitioners who downcode might be more likely to be flagged for an audit if their services are consistently below average.

Is Downcoding legal?

The aforementioned abusive coding practices are illegal. Laws that may be implicated include the False Claims Act, Anti-Kickback Statute, Stark Law, Social Security Act, and the United States Criminal Code.