Fighting Back When Insurance Companies Bundle Charges

Insurance bundling is the process where a payer will often lump separate charges together to pay your practice less.

For example, lets say you have a patient that comes in for evaluation of high blood pressure and you notice the patient has two suspicious skin lesions - one on their left arm and one on their stomach. You then make the determination to excise one and perform a biopsy on the other.

You code 99214 with modifier -25 (E&M for patient with high blood pressure); 11403 (stomach lesion excision, benign, 3.0 cm); 11100 with modifier -59 (biopsy of arm lesion).

Modifier -25 is to be appended to a CPT code that is a separate and distinct service that is provided during the same visit. If modifier -25 is not added to the evaluation and management code (99214) both lesion codes could be denied, or the 99214 code itself might be denied. Modifier -25 identifies to the payer that the codes are truly separate services that were rendered.

Modifier -59 is to be utilized for a distinct procedural service and alerts the payer that two services that usually would be bundled into the lesion code should be reimbursed separately because the biopsy (11100) was performed separately. The two lesions that were examined were definitely separate, distinct and unrelated to each other.

If the insurance company does not pay for each service and is ignoring the modifiers -25 and -59, ultimately they are bundling.

The best way to fight back against bundling is to track your claims submissions and check them against your explanation of benefits forms to ensure that all services are paid.

The following are indicators your payers may be bundling your services:

An E&M code is indicated but no payment was made because the carrier bundled the charge with that of an unrelated service. When the charge is listed but no payment was made because the payer bundled the charge with an unrelated charge for another diagnosis. When this occurs you will often see the following denial code, "Payment for this service is included in the fee for the procedure." When the modifier is listed but the payer omits the service modifier (such as the -25 or -59) and no payment is made. When the code is totally omitted from the EOB as though the service was never rendered. For instance, you coded an E&M code and a minor outpatient surgery on the same day. The claim was filed using the -25 modifier. When the EOB's are received, the only charge noted is the surgery code. The E&M code is not included.

Certain explanations on your EOB's may also indicate that the payer is bundling some of your charges. Examples are as follows:

Medical visit not allowed for separate reimbursement The procedure code submitted on your claim has been changed to one that better represents the services performed by your physician. Payment for one or more billed procedure codes has been denied because it is considered a component of this billed procedure code. Payment for this service is included in the fee for the procedure. This service is a component of a primary procedure. Payment for the primary procedure includes reimbursement for the related procedure.

Make sure and analyze your EOB's for an extended period of time to identify if any of the issues above exist in your practice. Make a list of the payers that are attempting to bundle and what CPT codes and procedures they are bundling so your staff will be aware of this and keep an eye out for it moving forward.

Once you identify any charges that are being bundled, go ahead and immediately appeal those with the payer. It's imperative that you address it immediately as each payer has a deadline in terms of when a claim can be appealed.

The bottom line is to not accept what the insurance company pays but to ensure that payment has been made in accordance with your contract and that no bundling is occurring.