NOV 30, 2022
Breaking Bundles
I am aware of the Medicare correct coding initiative (CCI) bundle of 92250 on the same day as 92133 or 92134. Can the edit be unbundled if the diagnosis codes are different? For example, 92250 with a glaucoma diagnosis and 92134 with a retinal diagnosis.
Also, do all other payers follow CCI edits or are there payers who will pay both codes if they have different diagnoses?
Answer:From the May 2022
EyeNet® Savvy Coder article
Are You Bewildered by Bundles? Test Your Coding Competency:
OCT and Fundus Photo
Q. When performed on the same day, CPT codes 92134 (OCT of the retina) and 92250 (fundus photo) are bundled with an indicator of 1. When is it appropriate to unbundle with modifier -59?
A. See if the payer has a published policy that provides specific scenarios for unbundling the codes and that offers guidance on what you need to document in the patient’s chart. If the payer doesn’t have such a policy, only bill for the test that contributes most to the medical decision making for the encounter.
Action steps. Research payer policies for testing services to identify which codes are bundled and which of those can be unbundled. To find Medicare Part B policies of your payers, visit
aao.org/lcds.
Other payers may not follow Centers for Medicare & Medicaid Services CCI edits. They may establish their own edits. Verify each individual payer’s policies.