Unbundling. Unbundling occurs when you bill multiple procedure
codes for a group of procedures that are covered by a single compre-
hensive code. This erroneously results in higher reimbursement.
Unbundling comes in many shapes and sizes, from fragmenting one serv-
ice into component parts and coding each component part as if it were a
separate service to breaking out bilateral procedures when one code is
appropriate. Another example is separating a surgical approach from a
major surgical service, as in reporting a laparoscopic hernia repair using
2 codes — one for a diagnostic laparoscopy and another for the laparo-
scopic hernia repair — when that approach is already included in the
laparo-scopic hernia repair code.
Upcoding. Then there's unbundling's cousin, upcoding. This is the
illegal practice of using a CPT code for a higher level of service
and a more expensive service than was performed or of doc-
umenting more specific conditions than the operative notes
warrant simply to meet medical necessity.
Misusing modifier -59. One of the most common
errors I see during facility audits is the misuse and
overuse of modifier -59, distinct procedural service,
which inadvertently snowballs into the unbundling and
upcoding of surgical procedures. Applying modifier -59
to each CPT code listed in an operative session waves an
ominous red flag for Medicare and the Office of Inspector
General. Modifiers are an integral part of coding, used to indi-
cate that some specific circumstance altered a service or proce-
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A U G U S T 2 0 1 7 • O U T PA T I E N TS U R G E R Y. N E T • 2 5
• COLLECT WITH CARE Unbundling, which is when you report separate codes for related services when
one comprehensive code includes all related services, is one of several troublesome billing practices.
