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If a code has both a technical and a professional component and you report the code without using modifier 26 or TC, youre claiming that youve earned reimbursement for both components. Instead, they often occur alongside other illegal, unethical, or fraudulent billing practices. If you have information about medical billing fraud, contact the attorneys at Price Armstrong. Pro-fee coders may consider appending modifier 52 Reduced services or modifier 53 Discontinued procedure to a medical code when a provider does not complete the full procedure or service described by that code. However, if a doctor performs a nasal endoscopy and the patient returns later in the day with a nosebleed, it would be appropriate to bill for cauterizing the nosebleed since that procedure did not occur while the endoscopy was being performed. If two providers try to bill for services provided to the same patient for the same procedures on the same date, its called double billing. We are a group of medical billing experts who offer comprehensive billing and coding services to doctors, physicians & hospitals. Append modifier GZ when you expect Medicare to deny payment of the item or service because it is medically unnecessary, and you issued no ABN. Medicare paid $7.4 billion to hospitals for those stays. Tips to Avoid Unbundling Codes The legal issues surrounding whistleblower protections are complicated, and obtaining relief for discharge, demotion, or discrimination as a result of whistleblowing involves knowing how to navigate relevant federal and state laws. The NCCI table shows that CPT code 15823 Blepharoplasty, upper eyelid; with excessive skin became bundled with CPT codes 92081 Visual fields exam; limited and 92082 Visual fields exam; intermediate on Jan. 1, 1996, and Jan. 1, 1998, respectively. The DRG and severity level are determined by diagnosis codes (ICD codes). A physician should not report CPT code 19301 (Mastectomy, partial ) plus CPT code 38745 (Axillary lymphadenectomy; complete). Before you report an E/M code on the same date as a procedure code with indicator 000 (0-day global), 010 (10-day global period), or XXX (global rules not applicable), consider that those codes include the pre-, intra-, and post-procedure work involved. Do not bill separately for an incidental procedure performed simultaneously as a complex one. In particular, Medicare and some other payers may accept KX for these types of claims: For instance, on physical therapy claims reported to Medicare, modifier KX may show that services are medically necessary and reasonable after the beneficiary has exceeded the defined threshold. It is expected that a doctor will cauterize a nosebleed if the nosebleed is occurring during a nasal endoscopy. The edit has a modifier indicator of 1, which means you may bypass the edit in appropriate clinical circumstances. Double billing also happens when providers bill for the same procedure first using an individual code and then as a bundled code. Medical billing experts also help lawyers by identifying unreasonable and fraudulent billings.