AVOID DENIALS when Reporting Unlisted Services and Procedures
By John S. Aaron, Jr., CPC
When submitting claims involving unlisted services or procedures, you may experience claim denials routinely, even when special reports are included. Very often, you can avoid these denials by knowing your payers’ specific requirements. For example, some payers have forms specifically for review of special reports when unlisted services or procedures have been rendered. This helps the payer to direct the claim properly.
You may receive an ambiguous denial, even when the payer requires very specific information. For example, your denial may state, “medical records needed.” You send the office notes associated with the visit, only to have the claim denied again because it was actually an X-ray report that was needed. Don’t get caught in that confusion: Ask the payer to explain exactly what’s needed.
Regardless of what your payer’s requirements are, follow them “to the letter” to make sure your provider is appropriately reimbursed—or at least to establish that the service/procedure has become an industry standard (more on this, later).
Know Necessary Requirements
Rendered services commonly require a special report because the CPT® and HCPCS Level II code sets do not specifically describe what was done. When submitting reports, consider highlighting or underlining the section that most identifies the procedure related with the unlisted code.
For example, Table A is a sample laboratory requisition in which the ordering physician has requested a prothombin time with international normalized ratio (PT/w INR) as a STAT. This will justify the use of CPT® 99199 Unlisted special service, procedure or report.
Table A: Laboratory Requisition
By highlighting this information and including it with your UB-04/CMS-1500, the payer is able to validate your reimbursement request. Consider also the category upon which the documentation requirements may fall, as shown in Table B.
Table B: Documentation Required for Codes
Make a Payment Suggestion
Because unlisted procedure or service codes are not assigned specific relative value units (RVUs), payers do not have a “standard” rate at which to reimburse them. Be sure to request a specific reimbursement amount, or you may be subject to accept what the insurance company has decided to pay. To justify your charges, include with your special report a comparison between the provided procedure or service and the “next closest” CPT® or HCPCS Level II code. Include relevant details such as:
- Was the claimed unlisted procedure more or less difficult than the identified comparison procedure?
- Did it take longer to complete (and if so, by how much)?
- Was there a greater risk of complication?
- How does post-operative care compare?
- If you’re providing durable medical equipment (DME) or drugs, what is the supply cost?
Such details can make a difference in the reimbursement you receive.
Special Services and Adjunct Codes
Health care providers may also need a way to report services above and beyond the basic services rendered. CPT® codes 99000-99091 fulfill this need. For example, I work under POS 81 Independent laboratory, where providers order specific tests under a STAT request. In addition to CPT® 99199 (found in the Medicine section under “Other Services and Procedures”) for the STAT, the claim will also include 99000 Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory for the pickup and transportation of the specimen.
Modifiers to Consider
As noted in the chart above, there are unlisted coding possibilities for DME and drug-related items. For orthotics and prosthetics, consider including modifier NU New equipment for any new DME not commonly billed (e.g., E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair). This will help the payer when reviewing the documentation you included for reimbursement considerations.
Check with the payer before submission to see if they have dedicated forms for these claim types. This ensures the information will be routed to the personnel qualified to perform a review of your documentation.
Category III vs. Unlisted Procedure Codes
As you know, unlisted procedure codes in the CPT® codebook often end in 99 (e.g., 15999 Unlisted procedure, excision pressure ulcer) and appear last in a list of similar and/or anatomically related procedures (usually under the heading “Other Procedures”). But not all medical services absent a specific CPT® code should be assigned an unlisted procedure code.
If an unlisted procedure code has been submitted, the payer may deny your claim citing that a more appropriate service code is available. These codes may come from CPT® Category III, and are distinguished by a “T” suffix (e.g., 0221T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar). The “T” signifies the clinical efficiency and outcome of such emerging technologies has been considered temporarily.
When appropriate, report Category III codes (rather than an unlisted procedure code), not with the objective of reimbursement, but instead to further the cause of regular code assignment, and to aid in data collection and utilization reporting. This helps to prevent the temporary code from falling victim to the five-year sunset period. Consistent, appropriate reporting of Category III codes is key in the CPT® Editorial Panel’s consideration for permanent codes.
The Health Insurance Portability and Accountability Act (HIPAA) Version 5010 implementation guide advises that any procedure performed with “unlisted” included in the descriptor must include a corresponding description of the services rendered. With HIPAA 5010 formatting now in effect, check with your electronic health record (EHR) billing vendor to see if there is a way to upload this information upon claims submission. The objective is to remain HIPAA compliant and give payers no reason to deny your claims, or to request even more documentation. Although medical records are requested routinely, some payers will not accept amended information after a certain time. Keep this in mind and provide proper documentation the first time around.
John S. Aaron Jr., CPC, is a senior client billing representative for the Chicago Business Unit of Quest Diagnostics. He is president-elect for the Northbrook, Ill. local chapter and a member of Medical Billing Advocates of America, specializing in the area of patient advocacy.