Are Unbundling Codes Illegal?

Upcoding & Unbundling are considered to be unethical billing practices. The Centers for Medicare & Medicaid Services (CMS) says that “[m]isusing codes on a claim, such as upcoding or unbundling codes” are unethical billing practices.

What would happen if a medical office is caught unbundling codes?

Unbundling or fragmenting billing codes illegally increases a provider's profits by billing bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid. The use of electronic health records (EHR) software can facilitate upcoding and unbundling.

What is an example of unbundling codes?

Unbundling (also known as fragmentation) is the billing of multiple procedure codes for a group of procedures normally covered by a single, comprehensive CPT code. An example of unbundling is billing parts of a single, whole procedure separately.