Document “Unlisted” Procedures Thoroughly to Ease Payment

Providers hear over and over again how important their documentation is to ensuring proper code selection and, ultimately, optimal compliant reimbursement. But the documentation stakes are even higher when there isn’t an appropriate code to describe the procedure or service performed.           

You should never report a code that “almost” describes the procedure or service performed. Instead, the CPT® codebook includes unlisted procedure codes to allow you to submit claims for services that have no specific CPT® descriptor assigned to them. Insurers consider claims for unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Here are a few documentation pointers for providers to ensure that such claims do, indeed, gain payment.

Describe the Procedure in Plain English: Any time you file a claim using an unlisted-procedure code, include a separate report that explains, in simple, straightforward language, exactly what you did. You might also include diagrams or photographs to better help the insurer understand the procedure. Some practices recommend highlighting, or making notes on the operative report, to indicate where the provider describes the unlisted procedure.

Don’t forgetdocumentation of medical necessity to back up the decision to perform the procedure. Some practices include copies of articles in medical journals supporting the reasonableness of the procedure, such as clinical trials and medical indications.

Include a cover letter: When submitting an unlisted-procedure claim, your documentation should also include an explanatory cover letter.

Example: A young child requires a post-fistula tracheotomy tube change. The child is restless and unruly and will not submit to the procedure in the physician’s office. Therefore, the doctor elects to perform the procedure in the operating room with the patient under anesthesia. In this case, your best code choice is 31899 Unlisted procedure, trachea, bronchi. Your documentation might state

I performed 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 therefore we are submitting an unlisted procedure code.

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.

Also, note the specific ways that the unlisted procedure differs from the next-closest procedure listed in CPT®. This explanation will help relate the procedure performed to an existing procedure as support for reimbursement. 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 isn’t mandatory.

If you’re submitting an unlisted procedure code for a particular service, often, consider meeting with the payer’s medical director to discuss how you might be paid for the service without documenting the service so extensively for each claim. The payer may create a dummy code for the procedure, or set a fee for the unlisted codes, facilitating automatically adjudication.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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