Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgical procedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:
A) Upcoding
B) A wrap-around
C) Churning
D) Unbundling

Question

Quizplus · Accepted Answer

This scenario describes unbundling, which occurs when separate charges are submitted for services that are typically included in a single code or billing. In this case, the charges for the preoperative physical examination and postoperative care should have been included in the surgical procedure code itself. Upcoding refers to submitting a higher-level code than what was actually performed, a wrap-around is not a recognized term in healthcare billing, and churning refers to conducting excessive medical tests or procedures solely for financial gain.

Dr Leona Koenig Removed the Appendix of a Plan Member