Packaging Versus Bundling: Let the Battle Begin

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There are very important differences between packaged services and bundled services. Unfortunately, many people use these terms interchangeably, which may result in incorrect coding practices (and, potentially, in lost revenue for the organization).

Packaging is a reimbursement term. It refers to the practice of making a single payment that includes payment for a significant procedure as well as for the minor ancillary services associated with the procedure. CMS frequently uses this term to define the services for which it will not provide separate payment. Even though CMS may not provide payment, however, the codes for these services should still be reported on the claim form, unless contraindicated by CPT® coding guidelines or Correct Coding Initiative (CCI) edits. It is especially important that packaged services be listed so that CMS can collect accurate data about hospitals’ costs. In addition, not all payors follow Medicare payment policies, and they may provide payment in situations where CMS does not.

The issue of packaged services arises more often for hospitals than for physicians, but there are situations in which this concept can be confusing for physician billing as well. For example, in a freestanding center/IDTF setting, some payors will provide separate payment for radiopharmaceuticals, while others consider them a packaged service and will not provide separate payment. Unless instructed in writing by your payor, you should always submit a code for a packaged service so that the true costs of delivering the service are reflected on the claim form.

For the hospital side, CMS has an extensive listing of codes that it considers packaged, which also include imaging guidance, image processing, intraoperative services, and imaging supervision and interpretation.

All imaging-guidance codes (except, in limited circumstances, some of those for fluoroscopy) are unconditionally packaged—that is, separate payment will never be made for the imaging guidance. Instead, payment for the guidance is included in the payment for the associated procedure. For example, payment for a percutaneous liver biopsy (47000) includes payment for the ultrasound used to guide the biopsy (76942).

According to CMS, “An image processing service processes and integrates diagnostic test data that were captured during another independent procedure, usually one that is separately payable under the OPPS.” The 3D rendering codes 76376 and 76377 are the most frequently encountered codes from this category.

Intraoperative services refer to procedures that are “supportive dependent diagnostic testing or other minor procedures performed during independent procedures,” according to CMS. Though the term is confusing, this category encompasses interventional procedures, in addition to open surgical procedures. Although these are referred to as intraoperative services, CMS has clarified that they may be provided in conjunction with a significant nonsurgical procedure, as well as with surgery. This category includes procedures such as follow-up angiography (75898).

The imaging supervision and imaging (S &I) codes include the radiological S &I codes found in the radiology chapter of CPT, as well as codes 93555–93556, which represent imaging S &I services for cardiac catheterization. There are many rules and circumstances that define when these services are separately paid for and not packaged.

Since packaging is a reimbursement term and not a coding concept, the use of modifiers does not factor into packaged services. Applying a modifier, such as modifier 59, will not change the impact of the packaging policy. That is not necessarily the case with bundling.

Bundling

The term bundling refers to the application of coding rules to ensure that the procedure codes submitted on the claim accurately reflect the performed services. CMS uses National CCI (NCCI), which provides an overall set of guidelines that define how multiple procedure codes will be treated if submitted on the same date of service. Other payors may employ NCCI and/or other standards. For example, Blue Cross Blue Shield of Tennessee states that it applies bundling rules based on guidelines from NCCI, AMA, CMS, the American Academy of Orthopaedic Surgeons, the American College of Obstetricians and Gynecologists, and its own in-house clinical experts. ( http://www.bcbst.com/providers/code_bundling/)

Many times, the opposite term, unbundling, is used to describe improperly assigned