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Bundling Medical Insurance Codes – Stop Loosing Money To "Bundled" Medical Insurance Claims


What exactly is “bundling” anyway? It is when an insurance carrier combines two or more CPT codes, substituting one overarching code, often ignoring modifiers along the way. This practice can cut down on your receivables. When codes are bundled, the codes are grouped together and the insurance carrier will only allow the fee schedule allowance for the one code that they feel is appropriate.

There are ways to get around bundling. First you need to make sure you are billing the claim properly on the initial submission. For example, if you are billing for an E&M code for a patient who comes in with high blood pressure but the patient is also complaining of knee pain and you end up doing an aspiration of the knee joint, then you need to make sure you use the correct modifiers to indicate what you are doing. You want to bill the E&M code, say it is a 99213, with a 25 modifier to indicate that it is a separate and distinct service provided during the same visit. Then you would bill for the aspiration of the knee joint with the appropriate code using a 59 modifier to indicate a distinct procedural service.

It is quite necessary to know the proper use of all the different modifiers to get full reimbursement for your services. Also as important is the ability to read an EOB (explanation of benefits statement) correctly. EOBs can be fairly complicated and it is important to understand what the insurance company did with the claim.

When the claim is processed and you receive the EOB you need to make sure the insurance company allowed both codes separately. After all, you did an office visit to manage to high blood pressure and you did the aspiration which was completely separate from the office visit.

If the insurance carrier bundles your codes you should file an appeal. In many cases the insurance carrier will reprocess the claim and unbundled the codes if you go through the appeal process.

The appeal does not have to be complicated. It can be a form letter that you design where you just need to fill in the blanks. A lot of carriers bundle the claims on initial processing because the majority of offices will not appeal the claim. Just think how much money they save!

You may think that it’s not worth the time to appeal but you may be surprised if you knew how much money you actually lost over time. If you have a system in place to file the appeals that is a fairly simple process it won’t take much time and you can increase your receivables. In my opinion, it is worth the effort.

Copyright 2007 – Michele Redmond

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