Primary Care Coding Alert

Question: A carrier is denying a claim for a 99213 with an 81000 saying that the urinalysis is bundled into the evaluation and management (E/M) service. What is the best way to unbundle the service?

California Subscriber

Answer: No National Correct Coding Initiative (NCCI, or CCI) edit exists for 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) when it is paired with 99213 (Office or other outpatient visit for the evaluation and management of an established patient …).

The denial is most likely the result of a problem or payer-specific edit on the carrier’s end, so this would be one of those times when you will have to work with your payer on the issue. Provide them CCI edit documentation to show that the two services should not be bundled and instead be paid separately, and make sure that the documentation is going to the correct division and to the right person — or that person’s supervisor, if necessary — so you can get a long-term resolution to this claim and others like it. Sometimes, direct contact between a physician in your practice and a medical director at the carrier may be effective. Another alternative is to work through the provider relations representative assigned to your practice.

You may also want to try submitting the services with a modifier appended to one of the codes to see if that overrides the edit in question. Since the payer is bundling 81000 into 99213, you may want to append modifier 59 (Distinct procedural service) to 81000. In any case, as noted, some communication with the carrier is in order to clarify what is happening and why.