Wiki Bundled codes on the claim?

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mhammy67

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When two codes are bundled (ie: 67904 and 15823), do you

1) report the two codes together on the same claim, understanding that the 15823 will be denied because it is bundled with 67904 and you are only "reporting" the fact that the patient had both procedures.

2) NEVER included the bundled code on the claim and the insurance company only cares about what we want payment on.

3) report the two codes on the same claim and $0.00 zero out the amount for the bundled code showing we don't expect payment, but just letting them know it was performed.

My feeling is if it is bundled, you do not report it because it is considered a component of the other code and it's fraudulent to do so. But others feel we have to report ALL procedures no matter what, and I have also heard to report all procedures just for insurance company's to collect historical data. Any help would be appreciated.
 
You would not report it if it truly bundled. But with these two codes (67904 and 15823) a 59 modifier is allowed it is supported.
 
If it is bundled and cannot be supported as a separate site, etc. then you cannot modifier the procedure and you cannot report it separately, it is a component and has been reported when you use the comprehensive code. If you do report both the claim can either deny or the payer is allowed to pay the least expensive of the two procedures.
 
These codes are not bundled together. Even when using modifier 59, some payers like to deny, but when you call them, all you need to do is submit medical records. This happens quite often at our office. Due the the potential "cosmetic" nature of the codes, no matter how you code, you will most likely need to submit records, regardless for reason of denial. Its helpful to call the payer and ask them where you can send/fax records to. This way its documented on their end, and you will have a call reference# and claim# to reference on the records. And you correct, if the codes are truely bundled, you should not report them. Example, you do not report rib resection with a free flap. All this will do is deny payment for potentially the entire claim and delay cash flow.
 
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Marianne,

You are correct in not wanting to report codes that bundle. I agree with Debra, that unless the 2nd procedure was performed on the contralateral eyelid, the 15823 is not reportable. Medicare created and NCCI edit for these two codes as the 15823 is consider inherent to the 67904 when more than 75% of all surgeons perform them at the same surgical session on the same eyelid. Even though the CPT assistant from 2011 states otherwise and limited to those payers that strictly follow CPT rules only, this is does not apply to Medicare patients and carriers that follow Medicare NCCI edits; they must be performed on different eyelids.

http://codingnews.inhealthcare.com/...ery-coding-challenge-denials-for-15823-67904/

You don't report bundled codes for historical data. That is not correct coding and you are not sending in a clean claim. Even if you zero out the $ for the 2nd procedure, you just don't report it.

Not sure what CCI system ABONNELL is using, but they do bundle per Optum Encoder Pro and I checked the CMS NCCI tables also. As Debra stated, a separate incision, separate surgical session, separate anatomical location or separate lesion needs to be identified in order to use the modifier 59. Just because it's allowed does not justify applying a modifier 59, it must meet the definition of a separate procedure to turn off the edit.
 
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By saying they are not bundled together, I mean 15823 is not inherently a part of 67904. There is a difference between the 2 procedures and one procedure is not part of the other. While Medicare does bundle these 2 procedures, they may be reported together, with a modifier, if the documentation supports both procedures.
 
I agree with ABonnell, you should be able to bill both as long as both are documented. See below from August 2011 issue of CPT assistant.

"THEN

The CPT Assistant Newsletter (September 2000; p 7) cited the following regarding the reporting of blepharoplasty and blepharoptosis:

The fundamental difference between the blepharoplasty and the blepharoptosis repair is that a blepharoplasty is surgery on the skin of the upper eyelid and the orbital fat, while a blepharoptosis repair is surgery on the levator muscle of the eyelid. These procedures may either be done independently or together on the same eye depending upon the surgical indication. This would occur when the upper eyelid has redundant skin and the levator muscle is unable to elevate the eyelid to the normal position. When these two procedures are done on the same upper eyelid, both procedural codes are needed to accurately describe the procedure. The coder should include the multiple procedures Modifier 51 with the second code.

NOW

The instruction reported in the September 2000 issue of the CPT Assistant Newsletter remains correct, ie, it is still appropriate to report code 15823, Blepharoplasty, upper eyelid; with excessive skin weighting down lid, in addition to code 67904, Repair of blepharoptosis; (tarso) levator resection or advancement, external approach, when both procedures are performed on the same eyelid. It is also appropriate to append modifier 51, Multiple Procedures, to the second code.

Third-party payer guidelines may, however, differ from CPT coding guidelines, as both coverage and payment policy is determined by individual insurers and third-party payers. For reimbursement or third-party payer policy issues, please contact the applicable payer. "

Lorrae Aker, CPC
 
Bundle codes

I do agree with you all , you must all recognize that Diagnosis is what drives procedures rendered or performed. as long as Diagnosis permits service rendered, payer policy per edits will help you determine the appropriate codes to bill. I always code per Diagnosis and what clinical documentation support like Debra said.
 
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