What Does CPT Unbundling Mean?

A physician records the services that he provides to treat his patients using Current Procedural Terminology (CPT) codes. Each treatment has its own code, including a minor treatment that may be a part of a major procedure, such as surgery. An insurance provider determines how much to reimburse the physician by using the codes that he reports, so a physician may be able to increase his income by splitting a major procedure into several smaller procedures, which is known as CPT unbundling.

Significance

• Unbundling is worthwhile for the physician when the reimbursement rates for each individual treatment add up to more than the price of the combination treatment. According to Illinois, a physician reports conducting a metabolic panel, code 80048, instead of listing each lab test that the metabolic panel includes, such as testing the patient's blood calcium level, separately. If a physician can report 14 separate lab tests, and receive $20 for each lab test, collecting $280 is a better deal than reporting the lab tests as a group and receiving $250, but unbundling does not help the physician if the insurance company pays $300 for the group of tests.

Classification

• CPT unbundling is an error, not fraud, because the physician does report the actual services that she provides to the patient, but reports them incorrectly. The insurance company checks the physician's claim for any unbundling it suspects, and if it finds unbundling, it may reverse the unbundling, combining the minor treatments into the main procedure.

Detection

• The insurance company can search for unbundling by searching for certain codes on the claim for reimbursement. According to Wisconsin, if a physician submits two claims for treating cuts on small portions of the patient's skin, the insurance company may decide to reclassify these claims into a single claim for treating cuts over a larger area of the patient's skin. If the physician submits two claims for examining each of the patient's eyes, the insurance company can combine the claim into a single claim for examining both eyes.

Proper Use

• Unbundling is appropriate under certain conditions. According to Illinois, a physician should not report individual lab tests as part of a group procedure, even if they are normally part of a group procedure, when he does not conduct these tests at the same time. The physician adds a modifier code when he reports these tests to show the insurance company why he is unbundling them.