Medicare won't pay for unlisted codes

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aksockmonkey@gmail.com

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All - I am facing an issue that I am not sure how to tackle. As we all know there are some procedures that you have to use the unlisted procedure code as there is no CPT code for particular procedures. This is what we are told from Medicare: I called Medicare and I sent in medical notes but John from Medicare said that the claim was not going to be processed even with the notes. Medicare will not process claims with the description unlisted procedure. So I changed the description of the code and removed the word "unlisted" since that is what they are saying is the problem, but it was still denied stating Medicare does not pay for unlisted procedures and they feel there is another code that needs to be used. As we all know if I call Medicare and ask them what code they are referring to they will say they can't tell me how to code etc. I am truly at a loss as they won't pay for unlisted codes and are instructing me to purposely pick another code that I know is not the correct code. Suggestions?

Thank you in advance for any help or suggestions you can provide.
 
Are you sure its truly unlisted? One of my jobs is to review authorizations for unlisted code and see if there is a more appropriate code. Many times there is a more specific code and its really a coding error.
 
Unlisted codes are valid codes and when correctly used need to be reviewed by the payers for determination of coverage. I've never heard that Medicare 'won't pay' for these - I think you're being given incorrect information. I'll call Medicare and escalate the call to someone who can direct you to the correct process for how to submit these claims and the medical records so they get the correct place.
 
Have you filled out a NOC Code Documentation Form? WPS requires this for an unlisted code, along with the op note. Maybe your JMac does too.
Peg Smith CPC
 
Is it "Statutory Exclusion"? Generally those will not be paid, however you can try to appeal or have the patient appeal.

Lisa W
 
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