The World of Encoding and Medical Billing Fraud –- Part 2: Unbundling

by Andrea Vieten
Syringe, medical injection in hand. Vaccination equipment.
Header photo: Getty Images

As part of the Fraud Fact Friday series, our medical billing and encoding experts, Tami Rockholt and Mike Fossey, explain the problem of unbundling using the example of epidural steroid injections. To receive higher reimbursements, some providers code the provided medical services improperly by using the method of unbundling. Unbundling means that providers bill separately for procedures that are covered by a single, comprehensive Current Procedural Terminology (CPT) code.

https://www.youtube.com/watch?v=W52j1xQDpS0

Using RiskShield, health insurers can detect the improper application of codes for medical diagnoses and procedures. Using self-updating dynamic profiles, RiskShield develops a track of all billed procedures and identifies multiple CPT codes for which a single comprehensive code should be assigned.

This way, RiskShield identifies

  • The separation of one charge into parts which are coded as separate services
  • The use of related services when one comprehensive code includes all related services
  • The separation of surgical codes into more codes than called for by the American Medical Association (AMA)

Unbundling may occur unintentionally when the provider’s coding staff bills multiple codes based on misinterpreted coding guidelines or intentionally when multiple codes are being billed to maximize reimbursement. Regardless of the reason, unbundling is against the medical coding guidelines set out by the AMA. Unbundled charges can be directly denied using standard letters and result in direct savings. Within the user-friendly interface, RiskShield alerts unbundled charges and provides all information needed to dismiss the charges. RiskShield also provides the functionality to enrich predefined templates with case data allowing to automatically create denial letters.

Video Notes

Introduction (0:00)

Medical billing fraud introduction (1:49)

Epidural steroid injections (2:21)

Unbundling (3:50)

Tips to identify unbundling for epidural steroid injections (4:44)



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About the author

  • Andrea Vieten

    As a Senior Business Consultant at INFORM GmbH, Andrea Vieten has been responsible for managing global implementation projects in the financial industry. With more than 10 years of experience, she has consulted and guided many financial institutions to the successful implementation of intelligent decision systems in the areas of risk, processes and compliance.

    All posts by this author

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