Packaging Versus Bundling: Let the Battle Begin

There are very important differences between packaged services and bundled services. Unfortunately, many people use these terms interchangeably, which may result in incorrect coding practices (and, potentially, in lost revenue for the organization). Packaging is a reimbursement term. It refers to the practice of making a single payment that includes payment for a significant procedure as well as for the minor ancillary services associated with the procedure. CMS frequently uses this term to define the services for which it will not provide separate payment. Even though CMS may not provide payment, however, the codes for these services should still be reported on the claim form, unless contraindicated by CPT® coding guidelines or Correct Coding Initiative (CCI) edits. It is especially important that packaged services be listed so that CMS can collect accurate data about hospitals’ costs. In addition, not all payors follow Medicare payment policies, and they may provide payment in situations where CMS does not. The issue of packaged services arises more often for hospitals than for physicians, but there are situations in which this concept can be confusing for physician billing as well. For example, in a freestanding center/IDTF setting, some payors will provide separate payment for radiopharmaceuticals, while others consider them a packaged service and will not provide separate payment. Unless instructed in writing by your payor, you should always submit a code for a packaged service so that the true costs of delivering the service are reflected on the claim form. For the hospital side, CMS has an extensive listing of codes that it considers packaged, which also include imaging guidance, image processing, intraoperative services, and imaging supervision and interpretation. All imaging-guidance codes (except, in limited circumstances, some of those for fluoroscopy) are unconditionally packaged—that is, separate payment will never be made for the imaging guidance. Instead, payment for the guidance is included in the payment for the associated procedure. For example, payment for a percutaneous liver biopsy (47000) includes payment for the ultrasound used to guide the biopsy (76942). According to CMS, “An image processing service processes and integrates diagnostic test data that were captured during another independent procedure, usually one that is separately payable under the OPPS.” The 3D rendering codes 76376 and 76377 are the most frequently encountered codes from this category. Intraoperative services refer to procedures that are “supportive dependent diagnostic testing or other minor procedures performed during independent procedures,” according to CMS. Though the term is confusing, this category encompasses interventional procedures, in addition to open surgical procedures. Although these are referred to as intraoperative services, CMS has clarified that they may be provided in conjunction with a significant nonsurgical procedure, as well as with surgery. This category includes procedures such as follow-up angiography (75898). The imaging supervision and imaging (S&I) codes include the radiological S&I codes found in the radiology chapter of CPT, as well as codes 93555–93556, which represent imaging S&I services for cardiac catheterization. There are many rules and circumstances that define when these services are separately paid for and not packaged. Since packaging is a reimbursement term and not a coding concept, the use of modifiers does not factor into packaged services. Applying a modifier, such as modifier 59, will not change the impact of the packaging policy. That is not necessarily the case with bundling. Bundling The term bundling refers to the application of coding rules to ensure that the procedure codes submitted on the claim accurately reflect the performed services. CMS uses National CCI (NCCI), which provides an overall set of guidelines that define how multiple procedure codes will be treated if submitted on the same date of service. Other payors may employ NCCI and/or other standards. For example, Blue Cross Blue Shield of Tennessee states that it applies bundling rules based on guidelines from NCCI, AMA, CMS, the American Academy of Orthopaedic Surgeons, the American College of Obstetricians and Gynecologists, and its own in-house clinical experts. (http://www.bcbst.com/providers/code_bundling/) Many times, the opposite term, unbundling, is used to describe improperly assigned procedure codes. Unbundling is defined as the billing of multiple procedure codes for a group of procedures covered by a single, comprehensive code. There are two types of unbundling: unintentional, resulting from a misunderstanding of coding, and intentional, when an entity manipulates coding in order to maximize payment. Some examples of unbundling are:

• coding component parts of a procedure with separate CPT codes, such as separating the components of a procedure when one procedure code exists to describe what was performed accurately;
• reporting separate codes for related services when the code for the primary procedure includes all related services, such as separately reporting IV access and/or contrast administration for with-contrast procedures such as CT or MRI;
• coding a unilateral service twice instead of using one bilateral code; and
• downcoding a service in order to use an additional code when one higher-level, more comprehensive code is appropriate.

Again, not all payors use Medicare's National Correct Coding Policy (NCCP). Many third-party commercial payors use ClaimCheck or other proprietary rebundling software. As a result, services that may be considered separately payable by some payors could be bundled by other payors. The most commonly used bundling software package is CCI, which provides quarterly updates. Unbundling issues frequently appear in radiology in the following NCCP directives. When studies require contrast, there is not generally an established number of radiographs to be obtained because of patient variation. Accordingly, all radiographs necessary to complete a study are included in the CPT code description. CPT codes 99143–99150 (moderate sedation codes) have been assigned status C, or carrier priced, in the Medicare Fee Schedule Data Base and status N, or packaged, in the Hospital Outpatient Prospective Payment System schedule. Individual payor guidelines should be sought and reviewed for correct submission requirements. Unless specifically noted, fluoroscopy necessary to complete a procedure and obtain the necessary permanent radiographic record is included in the major procedure performed. Preliminary (scout) radiographs obtained prior to contrast administration or delayed imaging radiographs are often performed; when a separate CPT code is available to include these radiographs, it should be used. If there is no separate CPT code including additional views, it is assumed that these are included in the basic procedure. The injection of radionuclide is considered part of the nuclear-medicine procedure. Bone-survey studies require a series of radiographs; billing separately for bone-survey studies and individual radiographs obtained in the course of the bone survey is inappropriate Under certain circumstances, it may be necessary to bypass the bundling edits to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is important to remember that just because an edit can be bypassed does not mean that it automatically should be. It is critical that each situation be reviewed to ensure compliance. Modifier 59 indicates that the ordinarily bundled code represents a service performed at a different anatomic site, or at a different session, on the same date. Documentation must support a different session, a different procedure or surgery, a different site or organ system, a separate incision or excision, a separate lesion, or a separate injury (or area of injury, in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. The physician needs to document that a procedure or service was distinct or separate from other services performed on the same day. Before appending modifier 59 to a code, ensure that the documentation is clear as to the separate, distinct nature of the procedure. This modifier allows the code to bypass edits in many payor systems, so appropriate documentation must be present in the record. Modifier 59 should only be assigned if another modifier does not describe the situation more accurately. One of the challenges in the coding of radiology services is ensuring that bundling guidelines are followed correctly. For example, CCI does not recognize vascular families, so modifier 59 must be appended, in many coding scenarios, to ensure appropriate reimbursement. The original purpose of this application was preventing multiple catheterizations in the same vascular family from being paid for incorrectly. Modifier 59 should be used to designate the catheterization of additional vascular families when selecting multiple brachiocephalic or abdominal vessels. In summary, we frequently hear the terms packaging and bundling used interchangeably, but it is important to remember that they are not the same. Packaging refers to a payment policy and bundling refers to a coding policy. Bundling can definitely affect reimbursement, but packaging should not affect coding.