Bundling Denials Should Have Basis – Requesting Clarification

Bundling denials are highly problematic because various payors use different claim editing software to assess codes for compatibility. It becomes hard to determine why certain codes were bundled and what medical information might be persuasive in an appeal.

For this reason, many bundling appeals should focus on seeking clarification regarding why the codes were bundled and what policy or plan limitation applies to the denial. The payer may be using Medicare’s National Correct Coding Initiative guidelines or may be using proprietary coding edits. However, any denial should have some applicable rule or guideline that is consistently applied and available upon request.

Prior to appealing, review the medical records to make sure that all services were medically necessary and correctly coded. Also review your billing form to make sure that any appropriate modifiers were included. For example, modifiers –25 and –59 frequently affect which codes can be billed together.

If the codes do not appear correctly paid, your bundling appeal letter should also seek disclosure from the payer regarding what coding guidelines the carrier is using to assess the claim. If Medicare’s National Correct Coding Initiative is cited, this information is available at the cms.gov website. You can review the coding combinations to determine if you agree with the bundling by going to www.cms.hhs.gov/physicians/cciedits/. To review the CCI edits that apply to Medicare Part B services paid by Medicare fiscal intermediaries, go to www.cms.hhs.gov/providers/hopps/cciedits/. CCI is comprised of two different coding combination lists. The first contains the Column 1/Column 2 edits (formerly comprehensive/component edits) on a code-by-code basis. Check all codes in question to see if any are considered a component of the other codes. The second list contains mutually exclusive edits or edits which should never be billed together.

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