Wiki Calculating pricing for unlisted codes?

[Jessim929]

Hi All -

Recently one of my docs did a lap vesicovaginal fistula repair. I know there's no actual code for it, but it's comparable to 57320. How would I go about pricing it? Is there a generic formula for pricing unlisted codes for lap procedures? (like double the comparable code pricing, that sort of thing?)

Thanks!!

 

[csperoni]

There is no generic formula because unlisted is saying there is no existing code for this. Anytime you bill unlisted, you should be deciding the benchmark code and how it compares to that code. So if you are comparing it to the vaginal approach in this case, was this specific case more work, less work, or the same work as a vaginal approach?
If the same, I use the same fee.
If more work or less work, I come up with an approximation. 20% less work. 50% more work. Then increase or decrease my fee accordingly.
Uro not my exact specialty, but I will note that if I am coding an unlisted laparoscopic, I will usually benchmark to the open code, so 51900 in this case.
In fact, here's an article by Dr. Ferragamo @liqgold2@aol.com https://sufuorg.com/docs/coding/coding-corner-aug-2016.aspx stating exactly that - suggested to benchmark to 51900.

 

[liqgold2@aol.com]

I recently reviewed (not published) the Medicare charges for laparoscopic/robotic procedures and the same operative open procedures. The laparoscopic procedures in general depending on the procedure paid 14% to 24% more than the same open procedure. Therefore, the unlisted laparoscopy procedures should be billed 14% to 24% more than the bench marked open procedure. I would consult with the surgeon to make this call for the increase using the 14% to 24% guidelines.

 

[Jessim929]

Thank you so much! I was just at such a loss to even figure it out - we don't use unlisted codes for the most part, so I know so little about billing them. I know each instance is different, but having a general idea helps a LOT!!