Wiki Determining charges for unlisted CPT

Setting Fees for Unlisted Procedures


In our facility, we find the closest CPT to the unlisted, decide if the unlisted procedure performed involves more or less work, and set the fee accordingly.

Here's an article dealing with this for your review:

When reporting an unlisted procedure code it is important to include complete information in order to receive reimbursement. Unlisted codes require a detailed report from the physician or facility including time, skill and any necessary specialized equipment necessary to provide the service. In addition, the claim submission should include a detailed description of the procedure performed, clinical journal information and any cost savings experienced by utilizing this procedure. With respect to the charge amount, relate the ‘unlisted' procedure to an existing procedure in terms of amount of physician or staff work involved or facility resources expended

The use of unlisted procedure codes present a payment challenge for may insurance payors, but the submission of complete information will help ensure appropriate reimbursement.

How do you determine what to charge for an unlisted CPT that is not on Medicare Physicians Fee Schedule ? Any help would be great! Thank you!:confused: