Bundling and Unbundling of cpt codes: Common errors


In medical coding, the Procedure should be report with the most comprehensive CPT code that describes the services performed. The coders should not unbundle the services with other HCPCS/CPT code. There are many scenarios where coder will do downcoding or upcoding, which lead to denial of the claim. So, we should always the correct coding guidelines and should not bill any procedure which is bundle with the other procedure or which has been a part of a major procedure. So, we will look at few examples, which will help us to understand about the common mistakes we do while coding.
Bundling and Unbundling of cpt codes: Common errors

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The coder should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services. For example if a physician performs a vaginal hysterectomy on a uterus weighing less than 250 grams with bilateral salpingo-oophorectomy, the coder should report CPT code 58262 (Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)). This code 58262 automatically includes removal of tube(s) and/or (ovary) i.e. Salpingo-oophorectomy. Hence the coder should not report CPT code 58260 (Vaginal hysterectomy, for uterus 250 g or less ;) plus CPT code 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)).

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The coder should not fragment a procedure into component parts. For example, if a physician performs an anal endoscopy with biopsy, the coder should report CPT code 46606 (Anoscopy; with biopsy, single or multiple). Do not unbundle the procedure into coding Anoscopy CPT code 46600(Anoscopy; diagnostic) plus CPT code 45100 (Biopsy of anorectal wall, anal approach...). Simple trick to understand, is when we have a combination code we should not use individual Procedure codes.


The coder should not unbundle a bilateral procedure code into two unilateral procedure codes. For example if a physician performs bilateral mammography, the coder should report CPT code 77056 (Mammography; bilateral). The physician should not report CPT code 77055 (Mammography; unilateral) with two units of service or 77055LT plus 77055RT. Few Bilateral procedure have direct single CPT code, hence the coder should not split them and code two unilateral CPT code, when we have a single bilateral Procedure code.
The coder should not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure. A coder should not report CPT code 49000 (Exploratory laparotomy) when performing an open abdominal procedure such as a total abdominal colectomy (e.g., CPT code 44150).
Coder must avoid downcoding. If a CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code. For example if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the coder should report CPT code 19302 (Mastectomy, partial...; with axillary lymphadenectomy). A coder should not report CPT code 19301 (Mastectomy, partial...) plus CPT code 38745 (Axillary lymphadenectomy; complete).
Coder must avoid upcoding. A CPT code may be reported only if all services described by that code have been performed. For example, if a physician performs a superficial axillary lymphadenectomy (CPT code 38740), the coder should not report CPT code 38745 (Axillary lymphadenectomy; complete).

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