Handle medical claims denials caused by bundling

You need to be careful of what you report “together” on the same date. You cannot also unbundle and submit the claim with multiple provider names from the same practice. 

Categorized as Operations Tagged

You will have situations where you need to be careful with modifiers. 

There are services (per payer) that are considered integral to another service that’s reimbursed. This is called bundling. Most payers will have some technology based logic that disallows separate payments for each line item. These CPTs will be reimbursed as a bundle.

Make sure you are up to speed on all the bundled services and reimbursement policies. Use NCCI for guidance on the same. 

You need to be careful of what you report “together” on the same date. You cannot also unbundle and submit the claim with multiple provider names from the same practice. 

Make sure you review the documentation properly. You will see the denied claim line item that’s related to the bundled service/line item. You cannot just blindly resubmit the claim with a modifier. You need to have supporting documentation to be able to appeal that claim or resubmit that claim.

You need to understand AND have a “ready to go” checklist per payer.

This checklist should have this intelligence to show you whether a CPT is bundled in payments by that payer.

Most importantly, keep building this internal database of yours.

The workflow you are using here (or modifying) is that the billing department analyzes the denials, forms buckets, then trains / informs the coders to make corrections upstream. This strategy allows you to reduce such denials moving forward.