By: Kendall Upton
Professional insights: Olga Lyubar
Medical coders play an indispensable role in healthcare billing processes. They translate medical records and physician documentation into standardized codes which represent the diagnoses and procedures patients receive. Medical billers then use these codes to submit claims to insurance providers for reimbursement.
One major component of medical coding is code bundling. Students learn about code bundling in medical coding programs, but it’s a complex technique that can stump even the most seasoned coders.
What is code bundling in medical coding and billing?
Code bundling isn’t much different than it sounds. It’s kind of like a combo meal at a fast-food restaurant—one price for the items included, such as an entrée, side and a drink. In a medical coding context, multiple components of a procedure are bundled under one CPT or HCPCS Level II code.
“There are codes that we provide for diagnoses, and then there are codes for procedures. Code bundling is talking about the codes for procedures,” said Olga Lyubar, Department Head for Health Information Management and Medical Billing and Coding at Clark College in Vancouver, Washington.
“Maybe a patient came in to get a procedure done, and in addition to that we had to provide another procedure. In those cases, there are certain times where you can bundle those procedures together because it just comes along with it. For example, if there’s a surgery being done and something happens within that surgery, and if it’s part of the ordinary—let’s say there’s some bleeding and it needs to be stopped—that’s part of that surgery. We can’t put a separate code for that and charge them extra.”
By bundling together many small procedures that are inherent within a larger procedure, it simplifies the coding process so that coders don’t have to manually input codes for every little component. Plus, it reduces the overall cost for the patient because they aren’t being charged separately for everything that should be included in a given procedure.
What is unbundling?
Unbundling in medical coding refers to charging separately for certain procedures that may normally be included in a code bundle—kind of like ordering à la carte from the fast-food menu.
“Now where a lot of fraud can happen is the unbundling, because then we’re bringing up the bill to a higher cost or requiring the patient to pay more money for something that was just part of the routine,” Lyubar said. In fact, Lyubar mentioned that some artificial intelligence (AI) programs that are being implemented in the medical coding field have had trouble with unbundling correctly.
But there are situations where unbundling is necessary. For example, if a patient goes home after surgery but then returns a few days later due to complications from that surgery, then the follow up care may need to be unbundled and charged separately because it happened on a different day, and it wasn’t an expected or inherent outcome of that procedure. Multiple diagnoses may also warrant code unbundling depending on the procedures or treatments performed.
Why they matter
Understanding how to bundle and unbundle codes is critical to the success of any current or hopeful medical coder.
“With the code bundling or unbundling, somebody who’s in the medical coding field needs to know specific rules and regulations—when it’s allowed, what kind of codes can be used, and where things can be bundled,” Lyubar said.
When done correctly, code bundling can help streamline the billing process and keep costs down for the patient. Bundling errors, on the other hand, can have severe consequences for patients, healthcare providers and insurance companies alike.
“Why it’s very important for medical coding students to understand it is because if they don’t understand how to properly code, they could be unknowingly creating fraud. And obviously they’re going to be evaluated, and then we’d have to pay fines and fees, and this also delays the billing process,” Lyubar said.
Where to learn more
Code bundling and unbundling are vital components of any medical coding program’s curriculum. Though formal coding education is a great starting point, mastery of these skills takes time and experience.
If you want to improve your code bundling skills, consider checking out any continuing education classes offered by the AAPC (formerly known as the American Academy of Professional Coders) or the American Health Information Management Association (AHIMA), two of the leading professional organizations within the field that also offer certifications for coding professionals. When it comes to coding for patients that have Medicare or Medicaid, the National Correct Coding Initiative (NCCI) from the Center for Medicare and Medicaid Services (CMS) can also be a valuable resource.
