An informational modifier is a medical coding modifier not classified as a payment modifier. Whistleblowers are crucial to the important mission of uncovering and stopping unethical medical billing practices. As per AAPC, a clear understanding of the differences in the rules pertaining to coding, billing and reimbursement are necessary to know when unbundling can turn potentially difficult. If a whistleblower faces demotion, harassment or discrimination for bringing attention to medical billing fraud, they are entitled to all relief necessary. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). There have been many successful whistleblower cases that have exposed fraud by healthcare providers that upcode treatment or services, or unbundle medical lab tests or groups of procedures. Unbundling also occurs when a coder charges for two services when the code for the major service assumes that the minor service is also provided. Based on the descriptor, an E/M encounter must meet the criteria below to qualify for separate reporting using modifier 25. Tips to Avoid Unbundling Codes The two codes in an NCCI edit are bundled together. Claim forms provide space for multiple modifiers. As per existing medical billing guidelines, you cannot fragment a service into parts and code each component separately. Insurance companies and the administrators of government programs (like Medicare and Medicaid) rely on the codes as a standardized description of the services and procedures for which the medical practice seeks payment. The FCA makes it illegal to submit a false claim for payment to the government by a government contractor. Read theseexamples of upcoding and unbundling multi-million dollar penalties shared by Phillips and Cohen( an international law firm). Consequently, for those payers that do not accept modifier 51, the MULT PROC column offers information about expected payment rather than about whether to use modifier 51. Append modifier GY when Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit. Immediate surgery is scheduled. Another important global package modifier is modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period. Correct coding for the surgery. Why Should You Hire A Medical Billing Company Right Before ThanksGiving? The medical record must support that the referring/ordering practitioner who ordered the test for a specific medical problem is treating the beneficiary for this specific medical problem. search for instances of unbundling in medical billings. Duke University. EndoGastrics device could be implanted through two procedures, one more invasive and more expensive than the other. You should not report an E/M code for that work, even with modifier 25 appended. Section 1.2 and Section 60.1.1 both state, Coinsurance and deductible are waived for moderate sedation services (reported with G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service and when reported with modifier 33. You enter the pricing modifier directly to the right of the procedure code on the claim. Duke settled the lawsuit for $1 million. When the third code exists, it is the correct code when the procedures are performed together. The MPFS lists fee maximums Medicare uses to pay physicians and other healthcare professionals on a fee-for-service basis.