Wiki bundling

[Slraheb]

Hi, Can anyone help me with this? My provider who is a MOHS surgeron bills all the MOHS codes (17311, 17312, 17313, 17314 and 17315) She has always billed these, most of the time with a repair, graft or tissue transfer. We have a Unitedhealthcare patient who they are bundling a 17313 and a 13121. Those codes do not get bundled, not with any insurance, I have called UHC several times to argue this but they are recouping the payment for that. Any suggestions on documentation or how I can fight this?

 

[thomas7331]

One thing you have to keep in mind is that bundling rules are often come from payer reimbursement policies rather than strict coding guideline and as such, can sometimes vary from payer to payer. Certainly, Medicare and most payers who follow NCCI guidelines do not bundle closures into Mohs procedure codes. As a reference, see Chapter 3, section F, of the CMS NCCI Policy Manual, which you can find here: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-3.pdf. On page 8 it explicitly states: Repairs, grafts, and flaps are separately reportable with the Mohs micrographic surgery CPT codes.

So, one of two things could be happening here - either 1) UnitedHealthcare has made an error in their claims system and is bundling inappropriately; or 2) they have adopted a policy that differs from Medicare and are making the repair inclusive to Mohs. If 1) is the case, then you should submit a written appeal (include documentation from the CPT manual and from NCCI) asking them to reverse the denial. If that fails, and they respond back that 2) is the case, then you and your provider will need to evaluate whether or not they have adjusted their fees for the Mohs procedures to compensate for your loss of revenue. If they are not giving you a higher fee for Mohs now that the repairs are inclusive, then your provider needs to have a talk with the UnitedHealthcare contracting representative and negotiate to correct the fees for these services. If that is not possible and they are unwilling to make an adjustment in your fee schedule, then your provider will need to make a business decision about whether to discontinue the contract and stop seeing those patients, or to simply continue and accept the reduction in revenue.

 

[Slraheb]

thank you