In 2001, the AMA published an article about unlisted procedures, they state that a code "close" to the service provided is not reported when it is identified that the service falls under an unlisted procedure code. It is published and known since 2007 that ganglion impar block is 64999 Unlisted procedure, Nervous System. Another code for the service can not be used based on the payers response. The appropriate action is have the doctor write a letter of medical necessity or plan in the future to let patient's with the particular insurance know that there is issue with their particular carrier paying for the procedure and that agreed upon price prior to the procedure could be set up with potentially the physician and the facility to cover the cost.
---------------------------------------------------------------------------------------------
AMA CPT Assistant 2001
Back to Basics:Unlisted Procedure or Service Codes
Due to advances in the field of medicine, physicians or other healthcare professionals may perform services or procedures for which the CPT book does not contain specific codes. To report procedures that are not otherwise specified, the CPT book designates unlisted codes. Unlisted codes do not include descriptor language that specifies the components of a particular service. Each section of CPT includes an unlisted procedure code number that should be used to identify unlisted procedures in that specific section of the CPT book. Within the guidelines of each section is information for use of the unlisted codes. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established in CPT to describe the procedure in question.
Unlisted codes do not describe a specific procedure or service, so when using these codes, it is necessary to submit supporting documentation (eg, an operative report, office notes) when filing the claim. This report is included to identify the specific information regarding the procedure(s) identified by the unlisted code. Relevant information should include an adequate definition or description of the nature, extent, and need for the procedure or service, as well as the time, effort, and equipment necessary to provide the service. The information may also include:
1) The specific service performed (including any assistance necessary to carry-out the service)
2) Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening
3) The number of times the service was provided, and
4) Any extenuating circumstances which may havecomplicated the service(s) or procedure.
Since unlisted codes do not include descriptor language that specifies the components of a particular service, these codes are reported without modifiers. Modifiers are used to indicate that a service or procedure performed was altered by some specific circumstance, but not changed in its definition or code. Since unlisted codes do not include descriptor language that specifies the components of a particular service, there is no need to "alter" the meaning of the code.
When performing two or more procedures that require the use of the same unlisted code, the unlisted code used should only be reported once to identify the services provided. This is due to the fact that the unlisted code does not identify a specific unit value or service. Unit values are not assigned to unlisted codes since the codes do not identify usual procedural components or the effort/skill required for the service.
It is very important that the CPT code accurately describe the service that was performed. For that reason, it is equally important that a code that is "close" to the procedure performed not be selected in lieu of an unlisted There are some who maintain that they are not allowed to use unlisted codes, or that the use of the unlisted codes is undesirable. While the use of an unlisted procedure code will require a special report or documentation to describe the service, correct coding demands that you use a code that is appropriate for the service being provided (ie, a code that most accurately represents the service provided), and not a code that is similar but actually represents another service.
--------------------------------------------------------------------------------
September 2007 page 10
Coding Communication:Surgery: Nervous System
Question: What is the appropriate CPT code to report for a ganglion impar sympathetic block?
Answer: Code 64999, Unlisted procedure, nervous system, should be reported. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, a procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service.
--------------------------------------------------------------------------------
