What is bundled services

There are a number of services/supplies that are covered under Medicare and that have HCPCS codes, but they are services for which Medicare bundles payment into the payment for other related services. If carriers receive a claim that is solely for a service or supply that must be mandatory bundled, the claim for payment should be denied by the carrier.

A. Routinely Bundled

Rebundling/Bundling: Reimbursement denial for any additional billed services that are components of or inclusive to, or mutually exclusive of a more comprehensive procedure performed in the same session by the same provider.


Unbundling: To inappropriately bill more CPT/HCPCS codes than necessary. Applied when certain codes represent procedures that are basic steps to accomplish a primary procedure already on the bill and, by definition, are included in the reimbursement of the primary procedure.








PROCEDURES AND RESPONSIBILITIES


When two or more related procedures are performed on a patient during a single session or visit, Oxford will reimburse the provider for the comprehensive code and deny or adjust the component, incidental or mutually exclusive procedure performed during the same session. The rebundling guidelines in this policy are based on The Correct Coding Initiative administered through the Centers for Medicare & Medicaid Services (CMS), AMA Current Procedural Terminology (CPT Code) and additional general industry accepted guidelines.




To rebundle a claim, Oxford claims system utilizes a software package assembled by IntelliClaim (owned by McKesson Health Solutions). IntelliClaim’s product provides a platform on which two off-the-shelf and widely used products (referenced below) are combined with a flexible environment that allows Oxford to develop, customize & update our payment guidelines as necessary. Through their product, the efficiency, accuracy and speed with which millions of edits can be applied, the detailed documentation supporting the logic behind the rules, and the clear explanations for claim adjustments result in more automated claim processing, faster turnaround, more consistent and understandable results, and improved customer service. As part of the IntelliClaim package, IntelliClaim has incorporated two software packages to rebundle codes. These software packages are the Correct Coding Initiative Software by The National Technical Information Service (NTIS) and effective October 6, 2006, ClaimsXten™ by McKesson.


The NTIS software provides Oxford with the Correct Coding Rules used by CMS. This software is the same software product used by fiscal intermediaries that process Medicare Fee for Service claims for CMS. The Correct Coding Rules can be found on CMS’s website at www.cms.gov. The IntelliClaim software incorporates the quarterly updates that CMS makes to the Correct Coding rules into Oxford’s claims processing system. ClaimsXten™ contains KnowledgePacks consisting of rules that, among other things, characterizes coding relationships on provider medical bills. ClaimsXten provides information that allows claims submitters, claims processors and adjudicators to identify potentially incorrect or inappropriate coding relationships by a single provider, for a single patient, on a single date of service. Examples of the rules include incidental, mutually exclusive, unbundling and visit edits. Sources of the KnowledgePacks include the AMA and CPT publications, CMS, specialty societies and McKesson physician consultants. Please note this Reimbursement policy is subject to Oxford’s reimbursement policies and rules. Refer to the Modifier Reference Policy for additional information

Injection services (codes 90782, 90783, 90784, 90788, and 90799) included in the fee schedule are not paid for separately if the physician is paid for any other physician fee schedule service rendered at the same time. Carriers must pay separately for those injection services only if no other physician fee schedule service is being paid. In either case, the drug is separately payable. If, for example, code 99211 is billed with an injection service, pay only for code 99211 and the separately payable drug. (See section 30.6.7.D.) Injection services that are immunizations with hepatitis B, pneumococcal, and influenza vaccines are not included in the fee schedule and are paid under the drug pricing methodology

For services provided between January 1, 1992, and December 31, 1993, carriers must not make separate payment for EKG interpretations performed or ordered as part of, or in conjunction with, visit or consultation services. The EKG interpretation codes that are bundled in this way are 93000, 93010, 93040, and 93042. Virtually, all EKGs are performed as part of or ordered in conjunction with a visit, including a hospital visit.

If the global code is billed for, i.e., codes 93000 or 93040, carriers should assume that the EKG interpretation was performed or ordered as part of a visit or consultation. Therefore, they make separate payment for the tracing only portion of the service, i.e., code 93005 for 93000 and code 93041 for 93040. When the carrier makes this assumption in processing a claim, they include a message to that effect on the Medicare Summary Notice (MSN).

For services provided on or after January 1, 1994, carriers make separate payment for an EKG interpretation.