Reporting Unlisted Procedure Codes
You may claim unlisted procedure codes only if an existing CPT® Category I or Category III code does not describe the procedure you wish to report. Per Chapter 1 of the National Correct Coding Initiative Policy Manual for Medicare Services, “A physician should not report a CPT® code for a specific procedure if it does not accurately describe the service performed. It is inappropriate to report the best fit HCPCS/CPT® code unless it accurately describes the service performed, and all components of the HCPCS/CPT® code were performed.”
Category III codes, although not always covered, allow providers to report the procedures so that claims data can be evaluated for frequency. This information is helpful when reviewing the need to replace a Category III code with a Category I code.
Unlisted procedure codes are identified as XXX99 or XXXX9 codes and are located at the end of each section or subsection of the CPT® codebook. A full listing of unlisted procedure also codes appears in the “Surgery Guidelines” portion of CPT®, prior to the 10000-series codes. Be sure to report the appropriate unlisted code for the category/type of procedure performed. For example, report an unlisted laparoscopy procedure of the esophagus with 43289 Unlisted laparoscopy procedure, esophagus, not 43499 Unlisted procedure, esophagus.
To facilitate claims adjudication for unlisted codes, include the operative report (if you can attach records) and provide a suggested fee by comparing the procedure to the type of work required for a similar procedure within an assigned fee schedule.
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