No Code? No Worries!
Three tips for getting unlisted procedure CPT® codes to work for you.
By Torrey Kim, MA, CPC
Question: What do the following procedures all have in common: Retropubic urethrolysis of a previously performed Burch colposuspension, laparoscopic distal pancreatectomy and splenectomy, electrosleep therapy, core decompression of the femoral head, thyroplasty, and endoscopic stapling of the diverticulum?
Answer: CPT® does not include codes for any of these services.
Question: What’s a coder to do when encountering one of these procedures in a physician’s notes?
Answer: Turn to the unlisted procedure codes in CPT®.
CPT® includes unlisted procedure codes allowing you to submit claims for services without specific CPT® descriptors assigned to them. You should never report a code that comes close to the procedure your physician performed but doesn’t quite fit. If no precise procedure or service code exists, you should report the service “using the appropriate unlisted procedure or service code,” according to the CPT® Instructions for Use section in the CPT® manual.
Payment for such claims is not automatic. With carefully documented procedures, however, the information you include with your claim can make all the difference. You can streamline your unlisted procedure code claims and ensure your physician gets reimbursed without using specific codes by following these three pointers.
Tip 1: Describe the Procedure in Plain English
Any time you file a claim using an unlisted-procedure code (for example, 90779 Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion), you should include a separate report to explain in simple, straightforward language exactly what the physician did. Make sure to compare it to an existing procedure and give it a relative value to that existing procedure, as well as provide the operative or procedure note.
Keep in mind that insurers consider claims for unlisted procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide.
It’s also a good idea to include diagrams or photographs to help the insurer fully understand the procedure. Some practices recommend highlighting or making notes on the actual op report indicating where the provider describes the unlisted procedure. Some practices include copies of articles in medical journals supporting the reasonableness of the procedure, such as clinical trials and medical indications.
Don’t forget medical necessity documentation to back up the decision to perform the procedure. For instance, you can include details such as “electrosleep therapy was performed to treat chronic insomnia that has not responded to other treatments” to reinforce medical necessity.
For Medicare Administrative Contractors (MACs) or third-party payers that no longer accept paper claims or require an electronic claim to proof for timely filing, submit your unlisted CPT® code electronically with a short description of what was done in box 19 of the Centers for Medicare & Medicaid Services’ CMS-1500 form or its electronic equivalent. Some MACs will then expect a faxed or mailed copy of your documentation after seven to 10 days, or will request documentation after receiving the electronic submission.
When submitting an unlisted procedure claim, your documentation should also include an explanatory cover letter.
For example, a young child requires a post-fistula tracheostomy tube change. The child is restless and unruly and will not submit to the procedure in the physician’s office. The doctor elects to perform the procedure in the operating room (OR) with the patient under anesthesia. In this case, your best code choice is 31899 Unlisted procedure, trachea, bronchi.
Your documentation should state, “The physician chose to perform the procedure under anesthesia in the OR rather than in the office because the patient was a young child who could not be safely restrained in the office setting. This was the best method to ensure a positive outcome and prevent any undue harm to the patient. CPT® does not contain a code to describe a procedure of this type, and we are submitting an unlisted procedure code.”
Tip 2: Compare the Procedure
An insurer will decide to pay an unlisted procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value.
Rather than leave it up to the insurer to determine which code is the “next closest,” you should explicitly make reference to the nearest equivalent listed procedure. After all, the treating physician is best equipped to make this determination. You also should note the specific ways the unlisted procedure differs from the next-closest CPT® procedure listed. This explanation will help relate the procedure performed to an existing procedure as support for reimbursement. Make sure to explain how your procedure differs to show why you didn’t choose the existing code. Basing your fee on a similar procedure is helpful in claims processing, but is not mandatory.
For example, the surgeon performs an arthroscopic bicep tenotomy, for which CPT® does not include a specific code. For this scenario, most coders recommend reporting 29999 Unlisted procedure, arthroscopy and requesting reimbursement at a level similar to 23405 Tenotomy, shoulder area; single tendon. The surgeon’s letter should explain the similarities and/or differences between the performed bicep tenotomy and a shoulder tenotomy.
Tip 3: Solicit Outside Advice, When You Can
Your surgeon’s professional association might offer recommendations of when an unlisted code is warranted and, if so, which “compare” codes they recommend. The AMA often offers unlisted coding guidance in its CPT® Assistant and other publications.
If the physician uses equipment and techniques for which there is no dedicated CPT® code, you may ask for the manufacturer’s aid to receive appropriate reimbursement. Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies. Use caution when applying manufacturers’ suggestions, however, because you are responsible for the accuracy of your claims. You should never misrepresent a claim to gain payment.
If your practice performs a particular procedure often for which there is no specific code, consider meeting with the MAC’s or payer’s medical director to discuss how you can get paid for this service without having to jump through hoops every time it takes place. The payer may create a dummy code for the procedure, or set a fee for the unlisted code, facilitating automatic adjudication.
Torrey Kim, MA, CPC, is the editor-in-chief of Part B Insider, a weekly publication that offers news and analysis on Medicare Part B issues. Visit the Part B Insider Web site at www.partbinsider.com.