Unbundling

The NCCI policy manual says a procedure is reported with the single code that describes everything performed, and it lists the forms unbundling takes. A provider does not report several codes when one code covers all of the services. A procedure is not fragmented into its component parts. A bilateral procedure code is not split into two unilateral codes. Services integral to a larger procedure, such as the surgical access, are not reported on their own. The same principle covers the surgical package: CMS’s fraud and abuse booklet gives billing an E/M visit the day after surgery, when the global fee already includes it, as an example of unbundling.

The procedure-to-procedure edits exist to catch it. Each edit pairs two codes that are not paid together for the same patient on the same date by the same provider, and when the pair’s modifier indicator allows no bypass, the column two code is denied. Medically unlikely edits do the same job for units of service. The manual also bars performing services on different dates to get around either kind of edit.

The mistake is treating the edit as the only test. A pair with a modifier indicator of 1 can be paid with a modifier such as 59 or XU, but only when the record shows the services were separate and distinct. Adding the modifier just to get past the edit is unbundling with an extra step. CMS created the X modifiers partly because 59 was so often used that way, and it ties that pattern to audits, appeals and even civil fraud cases.