Avoiding Unbundling | News | APMA
Avoiding Unbundling

February 21, 2023

ICD-10 on black keyboard

FACT: Choosing CPT® codes has nothing to do with dollars or RVUs.

There is no place for “strategic coding.”

References

Page xiv of the 2023 CPT Professional book[1] states:

“Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided.” 

Therefore, CPT codes should be selected based only upon choosing the code(s) that most accurately reflect the service(s) provided.

Chapter IV, Section A of the 2023 NCCI Policy Manual[2] states:

"A provider/supplier shall not report multiple HCPCS/CPT codes if a single HCPCS/CPT code exists that describes the services.”

Therefore, if there is one CPT code that describes the service provided, that code should be selected.  Choosing multiple CPT codes that represent elements of that procedure is “unbundling.”

Chapter I, Section A of the 2023 NCCI Policy Manual[2] states:

“A provider/supplier shall not unbundle services that are integral to a more comprehensive procedure.”

Examples

If a transmetatarsal amputation is performed, only the CPT code whose descriptor is “Amputation, foot; transmetatarsal” should be selected. Choosing instead to select CPT codes that represent partial resection of each metatarsal and the closure of the surgical site is unbundling and is inappropriate. In this case there is “a single HCPCS/CPT code exists that describes the services.” 

If the medial eminence of the first metatarsal head is resected and a first metatarsocuneiform joint arthrodesis of the same foot is performed, the CPT code whose descriptor is “Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthordesis, any method” should be selected. Choosing instead to select one CPT code to represent resection of the medial eminence of the first metatarsal head and another to represent the first metatarsocuneiform joint arthrodesis of the same foot is unbundling because there is “a single HCPCS/CPT code exists that describes the services.” Appending a 59 or X[ESPU] Modifier to one of these CPT codes on a claim form would indicate that the two services were performed on different feet.

If open reduction and internal fixation of a bimalleolar fracture is performed, only the CPT code whose descriptor is “Open treatment of bimalleolar ankle fracture, with or without internal or external fixation” should be selected. Choosing instead to select one CPT code that represents open treatment of a distal fibular fracture and another CPT code that represents open treatment of a medial malleolus fracture is unbundling because there is “a single HCPCS/CPT code exists that describes the services.”

[1] CPT 2023 Professional Edition Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983–2022 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).

[2] https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare/medicare-ncci-policy-manual


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