Unbundling (Fragmentation)

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.

HMSA pays for comprehensive services involving multiple procedures based on the single procedure code applicable to the group of procedures.

Claims filing information

For all claims, providers should bill only the appropriate code(s).

Example

The optometrist removes a small piece of jagged glass from the patient’s eye. Before the procedure, the optometrist applied a topical anesthetic to the area.

Claim contains:

• 65210 - Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating
• 00140 - Anesthesia for procedures on eye
• A4216 - Sterile water/saline, 10 mL

HMSA will:
Pay for the procedure (CPT code 65210) only. Topical anesthesia and routine supplies are included in the surgical fee and should not be billed separately. Furthermore, CPT code 00140 is used for general anesthesia rendered by an anesthesiologist and would not be an appropriate code to represent local or topical anesthesia.

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