Part B Insider (Multispecialty) Coding Alert

Home in on these five details for coding success.

Unlisted procedures might seem like the bane of a coder’s existence since you’re trained to always report the best-fitting, most accurate code for a service. When no such code exists, you might have to turn to an “unlisted” code that’s a catch-all for a range of procedures rather than a specific service.

All hope isn’t lost, however, because you can still score reimbursement for your provider. You just have to pay special attention to multiple details.

Detail 1: ‘Close’ Doesn’t Count for Coding

Getting close to the mark might win you points when playing horseshoes, but not when you’re coding your provider’s services.

Translation: Never report a code that comes close to the provider’s service but doesn’t quite fit. Instead, CPT^® instructs you to report the service “using the appropriate unlisted procedure or service code.” Each medical specialty has unlisted-procedure codes that allow you to report services that do not have a specific CPT^® code assignment. For example, two of the unlisted codes related to urology procedures include:

• 50549 – Unlisted laparoscopy procedure, renal
• 50949 – Unlisted laparoscopy procedure, ureter.

Detail 2: Documentation Can Bolster Your Chances of Payment

Codes that are associated with specific services are assigned reimbursement values. That isn’t the case with unlisted procedure codes because the codes can potentially represent such a wide range of services. Your first step in receiving adequate payment for unlisted procedures lies in clear, detailed documentation by the provider.

Start by including a cover letter stating why you are submitting the unlisted procedure code. This separate report should explain, in simple, straightforward language, exactly what the physician did.

Part of a coder’s job is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman’s terms. Including diagrams or photographs to better help the person reviewing your claim understand the procedure can further clarify the situation.

Expert tip: Ask the physician to include a paragraph at the top of the operative note explaining what the procedure was and why reporting an unlisted code is necessary. This lends further support to the cover letter you file with the claim.

If you’re worried that you might be overloading the payer with too much information, stop. Doing everything you can to make sure your provider gets paid what you think is appropriate includes sharing the details. Claims reviewers don’t necessarily have a high level of medical knowledge, and physicians don’t always dictate the most informative notes. Err on the side of giving the payer too much information rather than not enough.

“I recommend first sending in the claim electronically without the documentation so that you have proof of timely filing, and then sending the documentation with a statement on the claim saying that this is a documentation copy, not a duplicate copy,” says Barbara Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Detail 3: Search for the Best Comparison Code

Because unlisted procedure codes do not have assigned fees or global periods, payers will generally determine payment for unlisted-procedure claims based on the documentation you provide.

You can suggest a fee by comparing the unlisted procedure to a similar, listed procedure that has an established reimbursement value. This will help put your service in perspective with something familiar to the payer.

Tell the payer how the procedure you’re coding for compares to, and differs from, the assigned procedure code, Cobuzzi advises. Answer these questions for the payer in your documentation:

• Was the unlisted procedure more or less difficult than the comparison procedure?
• Did it take longer to complete and, if so, by how much (try to provide percentages whenever possible)?
• Was there a greater risk of complication?
• Will the patient require a longer recovery and more postoperative attention?
• Did the technique your physician use require special training, skill, or equipment?

Any of these factors can make a difference in the reimbursement level you may expect.

Example: The current CPT^® manual does not include a code for a simple robotic prostatectomy, which means you should submit the most appropriate unlisted code: 55899 (Unlisted procedure, male genital system). Because 55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed) is for a radical prostatectomy, do not use this code as a bench mark/referenced CPT^® code for the unlisted code.

Instead, benchmark to the open procedures 55821 (Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal…) or 55831 (…retropubic, subtotal), based on the laparoscopic robotic technique used, suggests Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

“Some carriers may also accept CPT^® codes 55821 or 55831 alone as definitive codes for the laparoscopic procedures,” adds Ferragamo, “as their definitions do not include a specific approach for the procedure.”

Detail 4: Be Prepared to Appeal if Necessary

Even the best documentation won’t always get you the reimbursement your physician deserves for an unlisted procedure. “If payment is not appropriate, you may need to appeal it,” Cobuzzi says.

Good advice: Get the name and department to whom you can send your unlisted procedure claim. That way, you can follow up on your request.

Sometimes manufacturer representatives might have helpful documentation about the equipment or technique that you could use as a second resource. But don’t rely on the reps to assist you with the coding aspect of the service.

You also can turn to specialty societies for help with appeals and documentation.

Bonus tip: When your provider repeatedly performs the same type of unlisted procedure, prepare an information file so you don’t have to reinvent the wheel every time you submit a claim. Each time a payer denies a similar claim, you will already have an appeals packet ready to send the insurer to defend your claim.

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