Coding and Billing

Description

The focus of this common issue is targeting claims where the procedure code includes imaging and imaging is billing separately.  This is known as unbundlng.

The following is one example.

Affected Code(s)

Explanation:

CPT 79999 is Radiopharmaceutical therapy

CPT 70010 is a Myelography (imaging study)

Explanation:

In this case the imaging (70010) is included and paid within the therapy code (79999). 

If unbundled (billed separately) the insurance company, Medicare or the patient is paying twice.

In January 1996, CMS implemented the National Correct Coding Initiative (CCI). This initiative was developed to promote correct coding of health care services by providers and to prevent Medicare payment for improperly
coded services.

The CCI developed into a sophisticated system of coding checks that eliminate duplicate and unallowed payments. Commercial carriers and state Medicaid agencies also employ this system.

The most effective method of identifying these duplicate claims is to examine the EOB (explanation of benefits). That is the document that looks like the medical bill.

Look for a service that was billed, but no payment was allowed or paid. The amount billed (but not paid) is not a legitimate medical claim.