received for potential duplication.
The claims are placed into two categories: exact duplicate or
suspect duplicate. Due to the nature of the service, some claims may only appear to be
duplicates. Proper coding of the service with the applicable condition codes or modifiers will
identify the claim as a separate payable service, not a duplicate.Exact duplicate claims will
contain the following:
HIC number
Provider number
From date of service
Through date of service
Type of service
Procedure code
Place of service
Billed amount
7. Upcoding or unbundling.
Upcoding refers to intentionally using a higher-paying code on a claim to receive a higher
reimbursement or billing a covered Medicare service in place of a not-covered service.
Unbundling refers to submitting bills piecemeal to maximize reimbursement for tests or
procedures that are required to be billed together. Upcoding refers to a provider’s use of CPT
Codes to bill a health insurance payer (private, Medicaid or Medicare) for providing a higher-
paying service than was performed. It is critical to understand that upcoding is illegal. It is
considered fraudulent practice used by providers who bill for additional services not documented
and/or performed. Another common example of improper coding called “unbundling,” also
known as “fragmentation.” Some health care providers seeking to increase profits will
“unbundle” the tests and/or procedures and bill separately for each component of the group,
which totals more
than the special reimbursement rates. We must be aware that doing this by adding modifiers does
not make this practice acceptable or legal. Medicare reimburses surgeries based on a package of
care (global surgery package). When unbundling for the purpose of receiving additional
payments although may seem profitable is illegal. It is very important to understand the usage of
modifiers and there purpose in the role of coding. Surgeries are designated in the CMS Medicare
Physician Fee Schedule Database (MPFSDB) with 0, 10, or 90 global days.
8. Further documentation requested to support medical necessity.
Sometimes a payer requires medical records before it can adjudicate a claim. This may include
the patient’s medical history, physical reports, physician consultation reports, discharge
summaries, radiology reports and/or operative reports. Medicare and private payers recognize
medical necessity as a deciding factor for claims payment and processing. Each payer might
have its own definition but the outcome is the same. The best way to stay within the bounds of
medical necessity is to think of each element of the history and physical exam as a separate
procedure performed only if there is a clear medical reason to do so. The key is always to have
documentation to support level of service should records be requested. No documentation equals
no services performed. According to section 1862(a)(1)(A) of the Social Security Act, Medicare
will not cover services that “are not reasonable and necessary for the diagnosis or treatment of
illness or injury or to improve the functioning of a malformed body member.”
9. Referral or prior authorization required.
Some payers require you to obtain authorization or a referral from another physician prior to
certain services or procedures being performed. There is a referral and prior authorization that is
at times required and it is important to understand the difference. The primary care physician,
who sends the patient to another healthcare provider for treatment or tests, issues a referral. The
payer to perform the necessary service(s) issues a prior authorization. It is understood by carriers
that obtaining prior authorization is still not a guarantee of payment. The submitted claim must
still be 1) supported by medical necessity, 2) filed within the timely filing requirements, and 3)
filed by the provider mentioned in the referral or authorization
