Rebundling Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

According to the Centers for Medicare and Medicaid Services (CMS), medical and surgical procedures should be reported with the Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes that most comprehensively describe the services performed. Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code. This policy does not apply to network home health services and supplies/home health agencies. 

For the purpose of this policy, the Same Individual Physician or Other Qualified Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number. 

Policy Codes

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  • 29866
  • 29885
  • 29887
  • 43235
  • 43239
  • 57023
  • 57410
  • 58150
  • 58700
  • 58940
  • 92502
  • 99173
  • 99211
  • A4550
  • G0442
  • G0447
  • G0473
  • J1642
* COMM-Rebundling-Policy.pdf
Click to Download: Rebundling Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans

Questions & Answers

Q: Are there other policies that deal with related information such as Laboratory Bundling, Evaluation and Management, and Anesthesia Services? How are those services considered? 

A: There are separate policies that encompass the Rebundling of Evaluation and Management (Global Days policy, Same Day/Same Service policy), Anesthesia Services, and Laboratory Bundling outside of the Rebundling Policy.

Q: How often are the Rebundling rules updated in each system?

A: Rebundling edits are updated quarterly. 

Q: Since the Rebundling policy recognizes many modifiers, do all modifiers bypass bundling edits in every situation? 

A: No.  There are many coding guidelines provided within credible third-party sources such as the CPT and HCPCS books, CMS NCCI Policy Manual, etc. that address situations in which a modifier applies.  While the Rebundling policy recognizes many modifiers, modifiers only apply when they are used according to correct coding guidelines.  For example, a surgeon performs both 29866 and 29885 during the same operative session on the left knee in the same compartment.  CPT parenthetical statement indicates, “Do not report 29866 in conjunction with…29885-29887 when performed in the same compartment.”  It would be inappropriate for the surgeon to report both 29866 and 29885 for the same date of service.  However, if the surgeon performed 29885 in a distinct and separate compartment of the left knee or during a distinct and separate operative session, an override modifier 59, XE, or XS may be reported based on which modifier is the most appropriate to describe the situation.  If the surgeon were to report a modifier LT on both 29866 and 29885 when performed in a distinct and separate compartment of the left knee or during a distinct and separate operative session, LT would be considered informational and bundling would still occur.  LT is an informational modifier and does not distinguish a distinct and separate anatomic location.

Q: Will heparin sodium, (Heparin Lock Flush), per 10 units (HCPCS code J1642) be reimbursed separately? 

A: HCPCS code J1642 intended for the flushing of a vascular access catheter/port or as a solution used for reconstitution or dilution purposes, is included in the practice expense portion of the relative value unit for the medical or surgical service and are not separately reimbursed, in accordance with CMS.

Q: Will vision screenings be separately allowed with Evaluation and Management (E/M) codes? 

A: No, vision CPT code 99173 (screening test of visual acuity, quantitative, bilateral) is intended to be done within the same session as an E/M service and is not separately reimbursed, in accordance with CMS. 

Q: How would the Rebundling edits handle the billing of a total abdominal hysterectomy (58150), salpingectomy (58700), and oophorectomy (58940)? 

A: 58700 and 58940 are not separately reportable services when submitted with 58150, as the descriptor of 58150 includes the services described in 58700 and 58940. The edit source is CCI.

Q: Are examination under general anesthesia services, 57410 (Pelvic examination under anesthesia) and 92502 

(Otolaryngologic examination under general anesthesia), separately reimbursable services when submitted with a surgical procedure performed in the same anatomical area? 

A: In accordance with CMS, examinations under general anesthesia are an integral part of the related surgical procedure performed in the same anatomical area. For example, 57410 (Pelvic examination under anesthesia) is not a separately reimbursable service when reported with 57023 (Incision and drainage of vaginal hematoma; non-obstetrical).

Q: Will UnitedHealthcare separately reimburse HCPCS supply code A4550 (Surgical trays) when submitted with another Evaluation and Management (E/M) service and/or procedure code? 

A: UnitedHealthcare follows CMS guidelines with respect to reimbursement for surgical trays (supply). Office medical supplies including surgical trays are considered to be part of a physician's practice expense. Therefore, reimbursement for a surgical tray is included in the practice expense portion of the relative value unit for the medical or surgical service. HCPCS supply code A4550 is considered included in the Evaluation and Management (E/M) service and/or the procedure performed in the physician's or other qualified health care professional's office. Please see UnitedHealthcare's B Bundle policy for additional information regarding code A4550.

Q: Why are Evaluation and Management (E/M) services not reimbursed with certain codes in the CPT Medicine section when performed on the same date of service by the same individual provider? 

A: Consistent with CPT guidelines, E/M services will be considered included in many medicine codes in the 9xxxx section of CPT and will not be separately reimbursed. Modifier 25 should only be used to report a significant and separately identifiable E/M service that is above and beyond the other service provided.

Q: Why isn’t the E/M service, 99211, allowed when reported with hydration, therapeutic, prophylactic, or diagnostic IV infusion or injections? 

A: According to CPT, hydration, therapeutic, prophylactic, or diagnostic IV infusion or injection services typically require direct physician supervision.  Since 99211 may be reported by qualified health care professionals other than physicians, UnitedHealthcare does not allow 99211 to be reimbursed separately when reported with these services whether or not a modifier is appended. 

Q: Are HCPCs codes G0442-G0447 and G0473 considered E/M codes? 

A: No, G0442-G0447 and G0473 are screening codes and are considered included in an E/M service.