Q&A: When a claim is denied on the basis of "bundling"

November 21, 2008
Virginia Martin, CPC, CHBC
Virginia Martin, CPC, CHBC

The author, president of Healthcare Consulting Associates of N.W. Ohio Inc., has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assi

Mutually exclusive code edits play a role in whether procedures can be bundled.

Q: Our surgery practice receives denials from insurers for procedures supposedly bundled together, yet when we check the current National Correct Coding Initiatives edits listing, we don't find the codes involved in the Column 1 or Column 2 edits. Is the insurer incorrect, or are we not looking at the correct resource?

A: A denial on the basis of "bundling" can originate in multiple places. Typically, the verbiage will read "this procedure is not separately reimbursable" or similar language. The first place to look is at the descriptions in the Current Procedural Terminology book. If the primary code descriptor includes other services (identified by CPT codes) and you are billing for the identified services, then no payment will be made. You indicated you have already checked the Column 1 and Column 2 edits, but you didn't indicate whether you checked the mutually exclusive code edits for bundled services. Mutually exclusive edits can be found at http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp.