Coding Q&A

Don’t presume that you can’t break a bundle


Don't Presume That You Can Break a Bundle


Q. I recently received a letter from a non-Medicare insurer explaining the results of an audit for overpayment of claims to the tune of $12,000+. All of the claims are for fundus photos and OCT done in the same visit (92250 w/59 modifier) dating back to 2007. My docs routinely do OCT and fundus photos on patients as part of their standard of care and Medicare has paid. The reason for denial of the claims now is, "This is a mutually exclusive procedure when reported with another procedure code billed." Has anyone else received this audit?

A. There are several critical issues that warrant attention in this question. Let's begin with the bundling programs. Medicare uses the National Correct Coding Initiative (NCCI) for their bundles and other insurers use a "secret" program with the evil sounding title "Black Box Edits." The Black Box Edits are private whereas the NCCI is public knowledge and is posted on the CMS website at One can safely assume the NCCI edits are incorporated into the Black Box Edits.

Early on, the philosophy and methodology of payment and auditing differed between Medicare and the other insurers. Medicare usually paid claims and then sometime later would audit and demand recovery of monies, whereas other payers would simply delay payment until the decision was made as to whether or not the claim should be paid. Auditing was infrequent. This has changed over the years and the other insurers began to audit. The question posed here is a good example of this.

When 2 CPT codes are bundled together (code edit pair) only 1 code is paid. If the bundling type is "Column I – Column II" then you are paid for the higher-paying code; however, if the bundling type is "Mutually Exclusive," then you are paid for the lowest-paying code (the code with the least Relative Value Units).

In a previous column, we discussed the dangerous and financially negative impact on the vitrectomy codes due to the Mutually Exclusive edits that were issued Oct. 1, 2008. In this particular ophthalmic diagnostic test scenario, we are dealing with a Column I/Column II type of bundle.

Both sets of bundles can be broken by applying modifier 59 when billing for the services if the code edit pair carries the proper modifier-indicator. However, the intent of allowing this disassociation for paired organ systems, such as ears or eyes, as expressed by Medicare, is to enable payment if the second procedure is performed on the contralateral side. Those of us in ophthalmology usually conceive of this as applying to unilateral procedures — multiple procedures or services performed on 1 eye.

Do not break an NCCI bundle simply because you do not agree with it or simply to facilitate payment. There should be a sound, medically necessary reason that the modifier is used. This is probably what happened in this case — the billing department had not been properly instructed in proper use of modifier 59. Its use has been an ongoing focus of the Office of the Inspector General and extensive use of this modifier has engendered audits with payment of monies, as this practice sadly experienced.

OCT and fundus photos were bundled due to previous fraudulent billing in the glaucoma arena. CPT code 92135 was originally developed for glaucoma imaging tests and then extended to retina.

Routine breaking of the bundles for this combination of codes should not be performed. There may be an occasional diagnosis where it could be justified, but hardly ever for each time the code pair is billed.

Remember that Medicare, and now other insurers as well, usually pay claims immediately and sometime later comes the knock on the door. The fact that Medicare pays a claim does not mean that it was billed correctly — it simply means you were paid — and they can and do come back! RP

CPT codes copywright 2006 American Medical Association.

Riva Lee Asbell can be contacted at where the order form for her new book "Tips on Ophthalmic Surgical Coding by Subspecialty" can be found and downloaded under Products/Books.