Of Code Bundling And Other Thorny Issues

Innumerable Medical Coding and Medical Billing Oversight Errors 

It is quite well-known that apart from the innumerable medical coding and medical billing oversight errors that medical practices usually oblige the insurance carriers with, a significant tool that the carriers themselves have conjured up to reduce reimbursements is “code bundling.”  CMS, BlueCross Blueshield, you name it, every one of them will more often than not have guidelines to downcode your claims.  And their defense is mostly a thinly-veiled excuse for slashing payments to clinics and practitioners, for duplicity of codes and other so-called unhealthy billing practices.

In the field of Radiology CMS has successfully reduced payments 75% of the time for certain combination procedures performed together, for example “facet joint injections which contain imaging guidance”- codes 64490-64495.  One might argue this is simply a case of CMS underplaying the effort of the technicians and refusing payment for a completely disparate procedure encompassed by the main one.  But the above scenario is a closed-and-shut case and radiologists have accepted the verdict of CMS and bundling of radiology codes continues in 2012 with the addition of newer pairs.

 Evaluation and Management Codes

Now there is an area in medical practice where knowledgeable billing and coding might counter this bundling effort and earn your cash-starved practice some much needed reprieve.  Yes, we are talking about “Evaluation and Management Codes”.  These codes are utilized for billing evaluation and management services provided in the physician’s office or in an outpatient scenario.  They are different from the codes used when the patient becomes an “inpatient” or is seen in the emergency room.

Rejections Citing Billing Costs

Consider that a patient is seeing a physician for a regular followup and he/she starts complaining of joint pain.  It happens that in the course of the visit the physician determines the joint pain to have a completely separate etiology, maybe a meniscal tear.  The physician in this case will most likely bill the additional E/M service with the code 99213 and the carrier also mostly likely will not treat it as a separate service and will pay for the followup alone.  The carrier thus ends up saving on the second fee schedule allowance.  Most practices do not bother to follow up on such rejections citing billing costs; but it is seen that in the long run such decisions are more detrimental than beneficial to the practice’s receivables.

If on the other hand you were using a medical billing service like “iSource”, chances are the coder would most likely have added the modifier 25 to the second E/M code to identify it as a distinct service and thus avoids rejection a majority of the time.  It is seen that even in the case of rejections with modifier 25 included, billing companies raise a dispute and this usually results in the carrier releasing that extra payment.