Otolaryngology Coding Alert

Payment for unlisted-procedure codes requires preparation and documentation

If you-ve ever filed a claim using an -unlisted- procedure- code, you know how much effort is involved. To ensure that payers properly reward your physician's effort (and your work in preparing the claim), our experts offer you three tips to improve your claim's effectiveness. 1. Don't Approximate The only time you should call on an unlisted- procedure code (for example, 31899, Unlisted procedure, trachea, bronchi; or 92700, Unlisted otorhinolaryn-gological service or procedure) is when no CPT code properly describes the procedure your ENT performs.

By the same token, however, you shouldn't select a code that is -close enough- in lieu of an unlisted- procedure code, says Heather Corcoran, coding manager at CGH Billing Services, a medical billing firm in Louisville, Ky.

For instance: You may select an unlisted-procedure code if the physician performs the procedure using a device other than what an existing CPT code describes or if the physician directs the procedure toward a specific anatomical location, but the intent of the procedure is somewhat different from an existing code. Crucial point: You should never select a CPT code -that merely approximates- the service the physician provides. If no precise procedure or service code exists, you should report the service -using the appropriate unlisted procedure or service code,- CPT guidelines state. Roll up your sleeves: Reporting an unlisted-procedure code will require a special report or documentation to describe the service. But correct coding demands that you use a code that most accurately represents the service the physician provides, and not a code that is similar but actually represents a different service. 2. Describe the Procedure in Plain English Anytime you file a claim using an unlisted-procedure code, you must submit a full operative report to describe the procedure or service.

Crucial point: When submitting an unlisted- procedure claim, you should file a -paper- (or manual) claim with the complete operative note and a cover letter that explains in simple, straightforward language exactly what the ENT did.

Note that some payers require an electronic claim as proof of -timely filing.- For these payers, file the claim electronically and then submit paper documentation with a note stating, -This is not a duplicate claim. This documentation supports an electronic claim.-
 
Here's why: Insurers consider claims for unlisted-procedure codes on a case-by-case basis, says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.

-Unfortunately, claims reviewers, especially at lower levels, don't always have a high level of medical knowledge, and physicians don't always dictate the most accessible notes,- Sandhusen says. Part of the coder's job in preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description [...]