It is not easy as it used to be to manage the financial aspect of any healthcare practices. The providers have to face complex challenges as day to day the Government is changing the rules and regulations. Anyone who is involved in the operational aspect of the medical office or healthcare facility understands that there are many situations that require making educated and rule-based decisions on various factors. Some of them being, use of the medical code bundling and the use of modifiers.
When it comes to choosing whether to bundle medical billing codes and/or to add code modifiers, providers are responsible for knowing what path will result in the smoothest transaction for the facility, the patient, and the insurance company. At the same time following all of the required industry rules.
Benefits of Bundling
When bundling the codes, it reduces the administrative work that accompanies medical services and is also meant to assist in providing accurate payments for the providers. By using one billing code to represent two or more health care services, the patient and/or insurance company is only billed for one amount, instead of receiving multiple bills. The services are combined and reflected under whichever service was more dominant. For example, if a patient receives a bone x-ray, and is treated for broken bone, the services would likely be bundled together under one code instead of two. This does lessen the paperwork involved in each transaction, saving time and money for the practice overall.
Even though bundling offers a variety of benefits but when done incorrectly can cause more issues than one can imagine. The purpose of code bundling is actually to simplify the billing process for all, therefore it’s important to understand when to bundle codes and why to use modifiers.
Drawbacks of Bundling
There is a potential for an issue to occur while bundling if the patient requires a service that doesn’t fall into a set of codes that can be bundled. This can put the practice with a pile of unexpected denials and providers at the risk of not being reimbursed for the additional services. In this situation, sometimes the providers avoid performing certain services or they end up billing the patient more than required, in order to ensure that they receive full reimbursement. This tactic of over-billing is call upcoding.
It is daunting for the physicians to know what should be and what shouldn’t be bundled. Therefore the CMS has developed the National Correct Coding Initiative (NCCI or CCI) edits to prevent inappropriate payment of services that should be avoided. All the NCCI tables are updated quarterly. To make things more precise and clear CPT modifiers are also involved, which supplies additional information when coding. It describes whether the multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body and how many surgeons worked on that particular patient.
For example, a surgeon performs a procedure to remove a bone cyst in the upper arm of the patient, but due to some complications, the surgeon was not able to completely excise the bone cyst. In this case, a reduced service modifier will be added as the procedure was not fully successful.
CPT modifiers require supplemental reports to the health insurance payer. There should be the highest level of specificity and provide as much documentation as possible. If a modifier is left without required justification then the claim may very well be rejected. To avoid this situation it will be in your great interest to outsource this service to an experienced and reliable source, permitting them to handle your RCM cycle.
The medical industry is constantly undergoing evolution. On one hand, compliance and self-pay are exponentially increasing, while on the other hand standards and regulatory requirements are demanding more time and efforts from the practices. Medical coding is one of the most crucial activities which have control over a practice’s financial health. As mentioned earlier, it would lead to the practice’s exposure to serious risk if proper focus and expertise along with effective infrastructure are not provided to assist the coding process. Just to organize the bills and sending it is not enough. iPatientCare provides experienced coders with specialty-specific expertise. They are aware of all CPT codes and are expert in tracking each record with its status and eliminating all errors and manual processes. Also, the coding process will be tailored to meet the unique principles of your practice. So availing these services will lead to increase in cash flow, improvement in claims submission, compliance risk will be reduced, will be dealing with the team (iPatientCare) that has in-depth knowledge about Revenue Cycle Management and seamless integration with the Medical Billing System. This way you are hands-free with this burden and can concentrate on core activities and improving your practice’s productivity.
About the author
Tejhas Vyass, a technocrat and result oriented with over 11 years of experience in US Healthcare Industry works with iPatientCare users during their inbreeding, involving, enrollment, training, configuration, and go-live assistance. He possesses an in-depth and up-to-date knowledge of the US medical insurance and revenue cycle management for small and medium sized physicians’ offices. An effective communicator with exceptional relationship management skills, iPatientCare users admire him for his knowledge, brilliance, and willingness to help during any and every step of implementation and support.