Medicare Compliance & Reimbursement

Myth: If the Correct Coding Initiative (CCI) doesn't bundle two procedures, then you are always free to report them together.

Reality: The CCI edits don't address every potential coding situation -- you must report only the applicable and most accurate code(s) for your physician's documentation, experts say.

"The CCI manual (in its introduction) specifically acknowledges that edits were not created to address every situation involving improper unbundling, but that this fact does not absolve the practice from coding a service correctly (applying the standard bundling/unbundling principles) when submitting codes," says Seth Canterbury, CPC, ACS-EM, education specialist with the University of Florida Jacksonville Physicians, Inc.

According to the CCI manual, "The edits and policies do not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination."

Keep in mind: "Even if Medicare's Correct Coding Initiative and its bundling edits didn't exist, there is the fact that the CPT book itself (in the introduction) refers to instructions included with many codes indicating whether it is proper or not to submit a code with another code or codes," Canterbury says.

In black and white: CPT states, "These instructions are not intended as a listing of all possible code combinations that should not be reported, not to indicate all possible code combinations that are appropriately reported. When reporting codes for services provided, it is important to assure the accuracy and quality of coding through verification of the intent of the code by use of the related guidelines, parenthetical instructions, and coding resources, including CPT Assistant and other publications resulting from collaborative efforts of the AMA with medical specialty societies ..."

Bottom line: "Medicare may not have created a specific edit to prevent us from separately billing something we may clearly realize is an always-included component of a comprehensive procedure," Canterbury notes, "but we're not off the hook, and it would be improper to just bill away, as it is not only the specific edits themselves, but the principles behind the edits (as stated in Medicare's National Correct Coding Initiative Manual) that must be considered, along with any information in the CPT book that discusses the appropriateness of reporting one code with another."

Could it be fraud? You may assume that if your carrier pays your unbundled charges, then it approves of them, but that isn't necessarily the case. Auditors could come back to you after the fact and investigate whether you coded correctly.

"I worked on an expert witness team for a physician indicted of criminal fraud," says Barbara J. Cobuzzi,MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. "One of the charges was unbundling and some of the 'unbundling' accusations weren't even CCI edits, but convention."During the fraud indictment, the U.S. Attorney's office calculated nearly $500,000 that the physician overcharged, all based on the government's belief that certain codes should not be billed together, whether or not CCI publishes advice against it, Cobuzzi says.