Unmasking Upcoding, Unbundling and Cross-Walking in PIP Claims
By Siona R. Bieber and Nathalie V. Acosta
At the recent FIFEC conference, we delved into the intricacies of upcoding, unbundling, and cross-walking in Personal Injury Protection (PIP) claims. These practices, if left unchecked, can lead to inflated payouts and increased costs for insurers. Understanding and addressing these issues is crucial for maintaining the integrity of insurance claims. This article, based on our presentation, provides an in-depth exploration of these concepts and offers best practices for identifying and mitigating them.
Understanding Upcoding and Unbundling
Upcoding involves using a billing code that results in a higher payment than the code that accurately describes the service provided. This can happen, for example, when untimed codes are submitted more than once per encounter, leading to higher reimbursements. According to Fla. Stat. §627.732(14), upcoding is the act of submitting a billing code that would result in a greater payment than using a billing code that accurately describes the services performed.
Unbundling is the practice of separating a procedure into multiple parts and billing them individually to increase the total payment. This is done even though the procedures should be billed under a single code. Fla. Stat. §627.732(15) defines unbundling as the action of submitting billing codes that should be included under one code but are separated into two or more codes, resulting in a higher payment.
The Importance of Identifying Upcoded and Unbundled Charges
Identifying and addressing upcoded and unbundled charges is crucial for several reasons. Firstly, these charges are not compensable under the PIP statute (Fla. Stat. 627.736(5)(b)1.e., 627.736(5)(d)). Secondly, consistent upcoding and unbundling can be deemed false and misleading statements under Fla. Stat. 627.736(5)(b)1.c., leading to legal and financial repercussions.
One common example is the unbundling of electrodes (CPT Code A4556), because two units should be included with codes G0283 and 97014 for electrical stimulation but are often billed separately. Another example is manual muscle testing (CPT Codes 95831, 95832), which is typically included in a physical examination but is sometimes billed separately to inflate costs. Evaluation and Management Codes (99201-99215), when billed on the same date as Chiropractic Manipulative Treatment (CMT) codes (989- codes), must include a modifier to be reported separately.
Case Studies and Legal Precedents
There are many cases which highlight the importance of proper billing practices and the consequences of unbundling and upcoding. In Associates in Family Practice of Broward v. Allstate*, the necessity of separate reports for manual muscle testing (CPT Codes 95831, 95832) was discussed. This case underscores the legal implications of improper billing and the need for rigorous oversight.
Best Practices for Identifying and Investigating Unbundled and Upcoded Charges
To combat these practices, insurance professionals must develop and enforce clear policies that ensure accurate billing. This involves regular staff training to educate employees on proper billing codes and the legal implications of upcoding and unbundling. Conducting periodic audits can help identify and correct improper billing practices. Employing software tools to detect patterns of upcoding and unbundling can also be highly effective.
Collaborating with coding and billing experts is essential, particularly in complex cases. Experts can provide insights into whether the billing codes used accurately reflect the services provided and help identify discrepancies.
Florida Statute §627.736(6)(b) provides a pre-suit framework for insurers to request detailed reports from medical providers, including treatment history, costs, and medical necessity. Medical providers must submit sworn statements (when requested) affirming the reasonableness and necessity of the treatment provided. Insurers must act promptly, typically within 30 days of receiving a bill, to request additional documentation.
Cross-Walking in PIP Claims
Cross-walking involves billing a service under a code that can be compensable under another code for a higher rate. For example, CPT Code 97014, which is used for unattended electrical muscle treatment, is not valid for Medicare purposes but can be cross walked to G0283, a valid code under Medicare.
Legal Framework for Cross-Walking
The general provision of Florida Statute 627.736(5)(a) provides the legal framework for proper reimbursement rates for CPT codes billed by medical providers when the applicable policy elects to limit reimbursement pursuant to State and Federal fee schedules. Specifically, Fla. Stat. 627.736(5)(a) states: However, if such services, supplies, or care is not reimbursable under Medicare Part B, as provided in this sub-subparagraph, the insurer may limit reimbursement to 80 percent of the maximum reimbursable allowance under workers’ compensation, as determined under s. 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided. Services, supplies, or care that is not reimbursable under Medicare or workers’ compensation is not required to be reimbursed by the insurer.
In Allstate v. Perez**, several district courts of appeals have interpreted the statute to mean that a “CPT code alone does not dictate whether a service is reimbursable under the statute… it is the nature of the medical service that controls.”
United Auto. v. Lauderhill Medical***, affirmed Perez. Even if a CPT code is not reimbursable or no longer recognized under Medicare part B, the insurance carrier must assess the medical records to determine the service represented and then determine if it is reimbursable under Medicare fee schedule.
On September 11, 2024, oral arguments for Allstate Indemnity Company v. Gady Abramson****, took place at the Third District Court of Appeals, where appellant, Allstate requested the Court to certify conflict with the 4th DCA’s findings in Lauderhill and to reverse and remand the trial court’s summary judgment in favor of appellee, Abramson.
Investigating Cross-Walked Charges
Investigating cross-walked charges involves obtaining detailed information through depositions, using pre-litigation requests to gather necessary documentation, and engaging experts to evaluate the appropriateness of cross-walked codes. For instance, in cases where CPT Code 97039 is used, insurers should investigate whether the service provided was hydro bed therapy, whirlpool therapy, or massage, as each requires different documentation and justification.
The Florida PIP Statute explicitly states that massage therapy is not payable under PIP: Medical benefits do not include massage therapy as defined in s. 480.033 or acupuncture as defined in s. 457.102, regardless of the person, entity, or license providing massage therapy or acupuncture, and a licensed massage therapist or licensed acupuncturist may not be reimbursed for medical benefits under this section. Fla. Stat. 627.736(1)(a)(5) (2024).
Florida Statute 480.033 defines massage therapy as follows: “Massage” means the manipulation of the soft tissues of the human body with the hand, foot, arm, or elbow, whether or not such manipulation is aided by hydrotherapy, including colonic irrigation, or thermal therapy; any electrical or mechanical device; or the application to the human body of a chemical or herbal preparation.
Conclusion
Proper identification and management of upcoding, unbundling, and cross-walking are critical for maintaining the integrity of PIP claims and ensuring fair compensation.
Key Takeaways
Understanding and identifying coded, unbundled, and “cross-walked” charges is essential for preventing inflated claims and maintaining the integrity of insurance processes. Implementing clear billing policies, training staff, conducting regular audits, using technology, and collaborating with experts can significantly reduce the risk of improper billing. Additionally, promptly investigating and addressing billing discrepancies through legal frameworks ensures compliance and accuracy.
By adhering to these guidelines, insurance professionals can mitigate the risks associated with upcoding, unbundling, and cross-walking, ensuring fair and accurate claims processing. This proactive approach helps uphold the principles of integrity and fairness in insurance litigation.
Citations:
*Associates in Family Practice of Broward, L.L.C. v. Allstate Fire & Cas. Ins. Co., 27 Fla. L. Weekly Supp. 761a (Fla. Broward Cty. Ct., Oct. 3, 2019)
**Allstate v. Perez,111 So. 3d 960 (Fla. 2nd DCA 2013)
***United Auto. v. Lauderhill Medical, 350 So. 3d 754 (Fla. 4th DCA 2022).
****Allstate Indemnity Company v. Gady Abramson, D.C., P.A., 3D23-797 (Fla. 3d DCA)