Elixir Medical Claims Management LLC

Back to Basic: All the Ways (Not) to Unbundle

A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services. For example if a physician performs a vaginal hysterectomy on a uterus weighing less than 250 grams with bilateral salpingo-oophorectomy, the physician should report CPT code 58262 (Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)). The physician should not report CPT code 58260 (Vaginal hysterectomy, for uterus 250 g or less;) plus CPT code 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)).

A physician should not fragment a procedure into component parts. For example, if a physician performs an upper gastrointestinal endoscopy with biopsy of the stomach, the physician should report CPT code 43239 (Upper gastrointestinal endoscopy …; with biopsy, …). It is improper to unbundle this procedure and report CPT code 43235 (Upper gastrointestinal endoscopy …; diagnostic, …) plus CPT code 43600 (Biopsy of stomach; …). The latter code is not intended to be utilized with an endoscopic procedure code.

A physician should not unbundle a bilateral procedure code into two unilateral procedure codes. For example if a physician performs bilateral mammography, the physician should report CPT code 77056 (Mammography; bilateral). The physician should not report CPT code 77055 (Mammography; unilateral) with two units of service or 77055LT plus 77055RT.

A physician should not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure. A physician should not report CPT code 49000 (Exploratory laparotomy,…) when performing an open abdominal procedure such as a total abdominal colectomy (e.g., CPT code 44150).