Practice Management Alert

If your carrier is constantly bundling claims you think should be unbundled, they're costing you a bundle of money  so get in there and fight for the reimbursement your office deserves.

Carriers often bundle claims that shouldn't be, because they count on the fact that 90 percent of providers won't challenge them, fumes consultant Quin Buechner, MS, M.Div, CPC, CHCO with ProActive Consultants in Cumberland, Wis. "It's a lot cheaper to pay the 10 percent who do than to pay the 90 percent who didn't."

And the fact is that many practices don't fight back when carriers bundle or deny claims because they're afraid to draw attention to themselves, experts note. But if you are coding correctly, you have nothing to fear, insists consultant Robyn Lee, MT with Lee-Brooks Consulting in Chicago. "[The physician is] providing the service and complying with all these regs. If all the documentation is there to support [the claim], you shouldn't be afraid to challenge" the carrier, she counsels.

Your first line of defense is the National Correct Coding Initiative (NCCI), and the second is the CPT book, Buechner and Lee agree. The NCCI tells you what codes are bundled and is updated quarterly, so it's essential that your practice keep up-to-date on this front, Lee says. "What might not be bundled this quarter might be bundled in the following quarter," she points out. And if you descend on your carrier with guns blazing, making claims based on outdated NCCI pairs, you'll not only fail to get the claim paid as you'd like, but you'll be highlighting your own ignorance.

The next weapon in your arsenal is the CPT book: "If CPT says something is not bundled or is only bundled when it's part of another procedure, copy those pages and send them [to the carrier]," Buechner instructs. Also remember that in some cases you can use modifier 59 to unbundle codes that normally would be paid as one, Lee notes. Of course, you'll need documentation to support this change, and you can verify that it's acceptable to use the 59 modifier by checking the NCCI.

Avoid this pitfall: Billing staff should never assume that simply because the physician says he provided two or more services, it means they can bill for the services separately, Buechner warns. Double-check the facts in the NCCI before challenging a bundled claim, he advises, because physicians often don't know much about billing. If you base your challenge on faulty assumptions, you'll only succeed in making the carrier wonder what else you're doing wrong.

Strategy for success: "You need to be assertive in dealing with these people, and you need to climb the ladder," Buechner encourages practices. The average claims rep "hasn't got a clue beyond his claim book what you're talking about," he says. That means you probably need to go over his head to reach someone who has the know-how to pay you appropriately.

But try not to take "too adversarial an approach," counsels Kent Moore, manager of reimbursement for the American Academy of Family Physicians. Rather than launching an outright attack against the carrier, give them a call or write a letter that is "professional in tone and practical in nature," Kent advises. Remember, you're simply taking care of business  making it personal or getting your feathers unduly ruffled will only aggravate the situation.