Unidentified Services Call for Unlisted Codes

Take steps to get these claims approved and paid appropriately.

By Pam Linton, CPC, CANPC
Medical advancements happen every day, but CPT® codebooks come out just once a year. The CPT® Editorial Panel simply can’t keep up. It stands to reason, then, that more and more services and procedures aren’t identified by specific CPT® codes. Sometimes, your only option is to use an unlisted code to report an emerging service or procedure. That shouldn’t deter a physician from providing appropriate, medically necessary treatments for his or her patients. Nor should you assume unlisted codes will never be paid. With clear, concise information and a little bit of preparation, proper payment for unlisted codes can become the norm, not the exception.

Straight from the Source

The CPT® codebook states, “Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.”
That sounds pretty straightforward, but the big question is: How do you convince a carrier to approve an unlisted CPT® code and adequately compensate your practice for the work, expenses, and risks involved with the service?
I’ve spoken to many payer representatives at seminars (Yes, payers attend coding and reimbursement seminars, too.) about this very subject, and they all concur. Best practices for getting an unlisted code paid are to:

  • Clearly explain exactly what the provider did, and that there isn’t a specific CPT® code to describe the service.
  • Provide an example of another CPT® code that is close in work and expense to the practice, and risk to the patient. This gives the payer valuable information as to the time and effort required for this service. Without a comparable code, you are leaving the entire decision-making process for reimbursement up to the payer, which could result in a reduced payment.
  • Submit with the claim additional, relevant information, such as previous treatments and outcomes, and procedure or visit notes.

Payer representatives will be the first to tell that unlisted codes with minimal or no additional information beyond the standard claim are often denied due to a lack of medical necessity.

Plan for Success

In addition to the above, the provider should detail in the record why this treatment was chosen over other treatment options. Any extra information to support medical necessity (such as a published study with favorable results) will go a long way in obtaining a positive outcome. Place all of this information together in one well-drafted document to submit with your claim. Submit this document and a copy of the procedure or visit notes with your claim.

Stand Your Ground

Even if you take all the necessary steps, you’re not guaranteed payment for services. Don’t be afraid to appeal any payment denials or seemingly inadequate payments.
Double check the address for where you mail appeals (it may not be the same as for claims). You want your appeal to be received by the correct department in a timely manner; and it’s a good idea to submit the appeal by certified mail with a return receipt. It may take more than one appeal to achieve the desired results.
Don’t be intimidated by unlisted CPT® codes. With proper policies and procedures in place, you can obtain a favorable outcome for both patients and physicians.

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Pam Linton, CPC, CANPC, is specialized in anesthesia and pain management coding. She has over 30 years in the healthcare billing industry, 16 of which have been with Zotec-MMP. Linton previously served as the office manager of one of Zotec-MMP’s Client Service Centers and is the anesthesia coding auditor and educator for Zotec-MMP. She has served on the academic advisory boards for South Florida State College in Avon Park, Fla., and Chattanooga State Technical Community College in Chattanooga, Tenn. She is a member of the Chattanooga local chapter.
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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