When Unbundling Is Okay for a Medical Coder

Sometimes, unbundling is supported and a medical coder can do so. For example, if the provider performs a procedure that is listed as inclusive but does so through a separate incision, you can unbundle the codes.

Perhaps the surgeon is working on more than one part of the body. If she performs a left knee meniscectomy (removing all or part of the meniscus, the pad of cartilage) and a right knee chondroplasty (shaving the cartilage), you’d unbundle the chondroplasty, even though a chondroplasty is always considered incidental to a meniscectomy. Why? Because it’s obviously not incidental when it’s performed on a different leg.

The edits are there for a reason: Unbundling procedures isn’t always okay. In fact, it’s often not okay. So how do you know what the edits are? You can find the Correct Coding Initiative (CCI) edits on the CMS website and in most coding software programs.

These programs are a good investment for most companies that bill surgeries, partly because they let the coder know when unbundling procedures is okay. Keep in mind, though, that some payers use their own editing programs that differ from the CMS version.

If your employer is contracted with a payer, the contract usually defines which set of edits to follow. Certain medical associations also have their own ideas about procedures that may or not be incidental to the main procedure.

In general, follow the CMS edits; if the payer says to do otherwise, then follow the contract.