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Unbundling is one of the most common medical coding errors, according to the American Medical Association. One medical procedure could have many parts to it, and each of those parts could theoretically be billed separately. But those components should only be billed separately when they are performed separately. When the multiple components are performed together as part of the same procedure, then the single procedure billing code is the proper one to use. Failing to bill correctly by unbundling services is a common billing mistake and a common source of Medicare fraud.

In medical billing, the whole is not greater than the sum of its parts. When each component is billed separately, the provider will get reimbursed more than if the procedure had been billed with the single, correct code. Unbundling medical codes intentionally to get more payment out of Medicare is an example of health care fraud, and Stacey Evans Law can help you blow the whistle on this harmful practice. If you become aware of a pattern of unbundling at the hospital, doctor’s office, nursing home, or medical billing and coding company where you work, call Stacey Evans Law in Atlanta. We represent whistleblowers throughout Georgia and can help you expose the fraud and be well-compensated for your efforts while ensuring you are protected from unlawful retaliation for blowing the whistle.

Understanding the Complicated World of Medical Billing and Coding

Current Procedural Terminology (CPT) codes were created by the American Medical Association (AMA) to standardize medical services reporting. CPT codes are the way medical providers report procedures and services to the insurance companies for reimbursement, including both private payers and government payers such as Medicare and Medicaid.

The entire set of CPT codes is updated every year, with new codes added, old codes deleted, and existing codes changed. Individual sections of CPT codes are also updated throughout the year. In addition to changing the codes themselves, the AMA is also constantly revising coding guidelines and medical terminology and nomenclature. Medical office staff in charge of billing and coding have a lot on their plate to stay updated and trained on current CPT codes.

Billing Mistakes and Fraudulent Unbundling

Medical billing involves submitting the right code for the service provided. Often one code will cover an entire service, even though several procedures are performed that each have their own billing code. When one code covers the service, that is the correct code to use. The provider should only use constituent codes when only that component is performed and not the whole service.

To try and prevent unbundling errors and fraud, the Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) Edits. The NCCI edits identify pairs of codes that should not be billed together. If two such codes are billed by the same provider for the same patient on the same day, the NCCI edits are supposed to catch the error and kick out the mistake, forcing the biller to use a different code reflecting that both services are really part of the same procedure.

Medical billing is a complicated area, and mistakes can arise from misunderstanding the coding system or failing to pay adequate attention to the billing process, especially when staff isn’t properly trained or supervised or kept updated on changes to the system. Because it is so complicated, medical billing is also ripe for fraudulent billing practices like unbundling.

Stacey Evans Law Helps Whistleblowers Report Unbundling Medical Fraud in Georgia

If you work in the medical billing field or otherwise become aware that a medical provider is intentionally unbundling medical services to swindle Medicare out of additional payments, Stacey Evans Law can help you blow the whistle and file a claim under the federal False Claims Act or the Georgia State False Medicaid Claims Act.  Sometimes the government takes over the case and goes after the provider themselves, giving you a share of whatever settlement or judgment they collect. If you wind up prosecuting the case yourself, you can collect an even bigger share of any monies recovered. In either case, Stacey Evans Law can prepare and file your case and provide skilled representation to help your case be a success.

You can root out fraud against the government and be rewarded for your efforts, and Stacey Evans Law can help. If you believe you have uncovered a pattern of unbundling medical errors in Georgia, call Stacey Evans Law in Atlanta at 404-850-6750 to discuss your concerns with a team of determined, dedicated, and dogged whistleblower/health care fraud attorneys.

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