Professional and Facility Industry Standard Coding Requirements Regarding Bundled Billing

October 2021

Neighborhood Health Plan of Rhode Island (Neighborhood) uses coding criteria and protocols established by industry standard sources including, but not limited to; the Centers for Medicare and Medicaid Services (CMS), the National Correct Coding Initiative (NCCI), and other specialty society guidelines. As you may know, CMS publishes NCCI edits, which are pairs of codes that should not be billed together. Each NCCI edit signifies a pair of services or procedures that normally should not both be billed when performed by the same provider on the same patient on the same day.

  • As a reminder to all providers servicing Neighborhood members (all lines of business), providers must not “unbundle” the services described by a Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) code. Unbundling is billing for procedures separately that are normally covered by a single, comprehensive HCPCS/CPT®

Please see the guidelines below for appropriate billing of services considered incidental, mutually exclusive, and integral to the primary service rendered, which are not eligible for separate reimbursement:

Incidental Services

An incidental procedure is carried out at the same time as a more complex primary procedure, but is not essential to complete the service and/or requires little additional provider resources. The codes do not typically have a significant impact on the work and time of the primary service.  Incidental services are not separately reportable when performed with the primary service.

  • Example: The removal of an asymptomatic appendix is considered an incidental procedure when done during hysterectomy surgery.

Integral Procedures

Services integral to HCPCS/CPT® code-defined procedures are included in those procedures based on the standards of medical/surgical practice. Some of these integral services have specific HCPCS/CPT® codes for reporting the service when not performed as an integral part of another procedure; other integral services do not have specific codes.

  • Example: Diagnostic endoscopy/arthroscopy is always included in surgical endoscopy/arthroscopy.

Mutually Exclusive Procedures

Many procedure codes cannot be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter. When mutually exclusive procedures are submitted together, the coding combination is considered submitted in error and only one of the services is allowed.

  • Example: The repair of an organ that can be performed by two different methods. Only one method can be chosen.

Please note that failure to furnish valid coding may result in payment delays or claim rejection.  Please see the following page for more information, including denial codes.

Valid procedural coding is required to process professional and facility services. Codes must be in effect for the date of service. Claims with missing or invalid coding are not considered complete claims.

If you do not adhere to the above guidelines regarding bundled billing, claims billed on or after November 1, 2021 will deny.   Neighborhood is contracted with NaviNet to provide 24/7 claims status lookup including additional claim detail for 317 denials.  The following denial codes/messages will display on NaviNet if your claim is denied for bundled billing:

Denial Code Denial Message
UNB Procedure code _____ has an unbundle relationship with procedure code ____ on claim ID _________ and line ID ___.
UIN Procedure code _____ incidental relationship with procedure code ____ on claim ID _________ and line ID ___.
UEX Procedure code _____ has an exclusive relationship with procedure code ____ on claim ID _________ and line ID ___.
SUN Per Medicaid CCI Guidelines, procedure code _____ has an unbundle relationship with procedure code ____ on claim ID _________ and line ID ___.

If you have any questions about this notice, please call Neighborhood Provider Services at 1-800-963-1001.