Perfect Your Unlisted Procedure Coding Skills

By Torrey Kim, CPC

When it comes to unlisted procedures, coding professionals fall into one of three camps. The first group overuses unlisted codes when reporting new technologies to avoid Category III codes. The second group under-reports unlisted codes because these codes can lead to documentation reviews and delay reimbursement. And the third group bills unlisted procedure codes only when no other CPT® or HCPCS Level II code describes the services that their physicians performed.

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Obviously, only the third group is billing properly, but insurance data tells us that quite a few practices still fall into groups one and two. According to Regence Blue Cross Blue Shield, the most common incorrect use of unlisted codes by their claimants is when practices submit unlisted codes even though a more specific code relevant to the procedure exists. Sometimes, the coding professional may not be aware of the more specific code available. Other times, the practice bills an unlisted code because it knows the applicable CPT® code is not payable for the patient’s condition. Either way, these are both examples of incorrect coding.

Practices should only use unlisted codes when absolutely necessary. If the CPT® book includes a more accurate code (even if it’s in Category III or HCPCS), report the more specific code. The only caveat to this rule is that some private payers may not accept Category III or HCPCS Level II codes and may prefer unlisted codes for certain procedures. If so, get this preference in writing from the payer. And in the absence of specific payer documentation, report Category III codes if they are available. For example, if the physician performs a total cervical disc arthroplasty, the correct code is 0090T, according to CPT® 2007.

The harsh truth is that if insurers never receive submissions of the Category III codes, the services will never get Category I CPT® codes assigned to them. That’s because Category III codes allow insurers to track the frequency of these procedures and, therefore, determine the need for permanent CPT® codes.

Modifiers are No Substitute for Unlisted Codes

Some practices avoid reporting unlisted procedure codes by simply modifying existing codes with modifiers 22 or 52, but this is incorrect as well.

For example, one otolaryngology practice submits all middle turbinate excision procedures with 30130-22. But 30130 refers to an excision of the inferior turbinate, and modifier 22 denotes unusual procedural services — not “other turbinates.” Therefore, the correct code for this claim would be 30999 Unlisted procedure, nose.

Coding professionals should use all resources available to seek an appropriate CPT® code for their physician’s procedures. If their research reveals that no specific code exists, then the unlisted code is appropriate to report. When submitting a claim with an unlisted code, you should also send a copy of the documentation and a letter from the physician explaining the surgery or procedure, as well as an example of a comparable CPT® code from a physician work standpoint, so the payer can determine reimbursement.

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