Coding & Reimbursement: Separate Procedures and NCCI Bundles
Date: October 1, 2024
Exceptions to restrictions and limitations exist, but understanding the exceptions and modifier usage is crucial.
On a regular basis, billers and coders confront a challenge when two procedures are performed on the same day for a patient. Can both procedures be submitted on a claim for reimbursement? Various limitations and restrictions apply, which make the answer not obvious. The potential for additional reimbursement creates a bias in favor of billing both codes — however, this may be an error and expose the practice to criticism. The Office of Inspector General of the Department of Health and Human Services has found that approximately 40% of such claims resulted in improper payments.
Discussion topics include:
- Separate procedure
- Medicare’s National Correct Coding Initiative
- Modifier 59
- When are the X modifiers used?
- XE Separate Encounter
- XS Separate Structure
- XP Separate Practitioner
- XU Unusual Non-overlapping Service
Published in: Ophthalmology Management - Vol 28, Issue October 2024
Written by: Corcoran Consultant, Brandy H. Sperry, COMT, COE, CPC, CPMA
Recent Articles
Coding Q&A: Medicare as a Secondary Payer
In certain cases, health care providers must determine whether Medicare is the primary or secondary payer to ensure correct billing and compliance with regulations. Some ...
Coding and Reimbursement: What’s New in 2024?
Find out what changed in coding and reimbursement this year and how it affects your ophthalmic practice in this article by Corcoran Consultants Mary Pat ...
Coding: Should You Perform More Laser Trabeculoplasty?
There are far more eligible patients than those who are receiving therapy. Not infrequently, an ophthalmologist or optometrist receives a critical letter that informs the ...
Coding & Reimbursement: Part C Medicare vs Traditional Medicare
We can expect enrollment in Medicare Part C, or Medicare Advantage (MA), to continue its two-decade long trend of growth. According to the Kaiser Family ...
Coding: Medicare Considerations of Compounded Drugs
Billing differs for FDA-approved and compounded drugs. Compounded medications can be beneficial in certain circumstances. This article discusses how they can be billed in a ...
Coding & Reimbursement: The ASC and Unlisted Procedure Codes
“All good things must come to an end,” and I’m afraid my authorship of this column is another one of those things. After more than ...
Coding: Cataract Documentation
As the most frequently performed ophthalmic surgeries, cataract procedures continue to receive payer scrutiny. Between the Targeted Probe and Educate audits, the 2022 Supplemental Medicare ...
Coding: Medicare Coverage of MIGS
A recent policy reversal for MIGS coverage by several Medicare Administrative Contractors raised questions about what’s next. In 2023, 5 Medicare Administrative Contractors (MACs) — ...
Coding Q&A: Part C Medicare vs Traditional Medicare
Practice managers must understand the implications of the shifting landscape. Medicare Part C, or Medicare Advantage (MA), refers to health insurance plans from private companies ...
Coding & Reimbursement: January 2024 Update
The new year brings important changes in the Medicare program.Here’s the lowdown for 2024. What coding changes will we see in 2024? What’s happening with ...
Coding Q&A: What’s New in Retina Coding for 2024
Revised E/M code descriptions and a new CPT code for suprachoroidal injections are among the changes. The American Medical Association recently released the Current Procedural ...
Coding: Non-Covered Services
Many practices assume that services without regular CPT codes are automatically non-covered and payable by the patient. At the same time, codes with allowed amounts ...
Coding: Stents and Visual Field Testing
Reimbursement for glaucoma surgery with an aqueous drainage device often depends on visual field testing. When considering an aqueous drainage device or shunt for glaucoma, ...
Clearing up confusion with refractions – Ophthalmic Professional
One of the most performed ophthalmic diagnostic tests is the refraction. Some level of refractometry is likely performed at most eye exams. Of course, a ...
Coding the Aborted MIGS – Ophthalmology Management
With the increased utilization of minimally invasive glaucoma surgery (MIGS) surgery in combination with cataract procedures, we find more instances where part of the planned ...
Steering Clear of Kickbacks – Review of Ophthalmology
Running afoul of laws regarding self-referrals and anti-kickbacks can result in heavy fines. Here's how to stay safe. Each year, the Centers for Medicare and ...
Dry Eye Disease and DEWS II – Ophthalmology Management
Dry eye disease (DED) affects millions of patients worldwide and is a common reason to seek eye care. A variety of DED therapies are available, ...
Identifying medically necessary services – Ophthalmic Professional
CMS' recent final rule provides guidance on what is considered reasonable and necessary.
Minor Surgery but Not Minor Documentation – Retinal Physician
To avoid payment denials, make sure your chart notes include the “how” and “why” of each procedure. To some people, the term minor connotes something ...
Are Screening Tests Reimbursable? – Optometric Management
As a follow-up to last month’s article on how often an optometrist can bill diagnostic tests for reimbursement, this month we discuss reimbursement for screening ...
Medical Record Signature Options – Retinal Physician
Medicare offers multiple ways to meet the requirement. Everyone knows that medical records must be signed to be valid. Let’s review Medicare’s specific requirements. Does ...
The Lowdown on Compounded Medications – Retinal Physician
Customization and lower costs help give these medications an essential role in patient care. Medications compounded for individual patients are an important part of health ...
2023 Update on Billing For Medications – Review of Ophthalmology
Injectable drugs got some new rules and regulations in the new year. Here’s what you need to know. 2023 brought changes to the rules for ...
How Often Can I Test for Glaucoma? – Optometric Management
A question that we receive frequently at Corcoran Consulting Group is “How often can I do this test?” Some Medicare contractors and other payors place ...