Wiki Unlisted Codes Submission

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kamer330

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One of the surgeons I work with frequently performs unlisted procedures. Since documents have to be submitted, the payment is delayed. They suggested I bill the claim without the unlisted code. Once it is paid, someone would submit a corrected claim adding the unlisted code. Can someone point me in the right direction to find the documentation stating we cannot do this? I want to give it to the surgeon. thanks
 
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kamer330 said:
One of the surgeons I work with frequently performs unlisted procedures. Since documents have to be submitted, the payment is delayed. They suggested I bill the claim without the unlisted code. Once it is paid, someone would submit a corrected claim adding the unlisted code. Can someone point me in the right direction to find the documentation stating we cannot do this? I want to give it to the surgeon. thanks
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In your place, I would refer the physician to the False Claims Act. I think that doing what has been suggested here could easily be construed as knowingly submitting a false claim to obtain payment to which the provider would not be entitled had they submitted the correct claim. It could also fall under the category of 'abuse' as this would be intentional manipulation of the claims system to attempt to get payment up front that they wouldn't be entitled to had they submitted the correct claim originally (and not to mention also costing the payers additional resources by forcing them to revise the claim at a later date). Are the delays your provider is experiencing really so costly as to warrant taking the risk of doing something that could trigger an investigation or audit which could end up potentially cost the provider even more?

There are better and more honest ways to go about this - Medicare, for example, has an electronic claims indicator that allows you to fax the operative report at the same time you are submitting a claim, will allows the processing system to tie the fax to the electronic claim, thereby minimizing delays in processing. Another option, for private payers, is to have specialized codes assigned in the contracts for procedures that your providers to with some frequency, which could expedite processing. Alternatively, the provider could negotiate special rates into the contract to compensate for delays in the processing that are necessary for the handling of these unlisted procedures if in fact the payers' delays are costing the business significantly.
 
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This is exactly what I was looking for. I will pass this information along and convince them this is not the direction to take. Thank you for your quick response.
 
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I agree with Thomas. Aside from the legal ramifications, it's just a terrible idea and plan on top of what Thomas explained. The amount of rev cycle work and re-work trying to send partial claims and then "correcting them" even though you knew they were incorrect in the first place would be unbearable. You would be delaying the payment and making mistakes even more/worse. Depending on the practice size, who is going to keep track of all that? It's hard enough keeping track of A/R in the first place. Not to mention, imagine being a patient on the receiving end of those EOBs, totally confusing. You'd probably generate complaints and patient dissatisfaction as well. I totally agree, if the provider is performing cases with unlisted CPT regularly, it makes sense to work with the commercial payers to build it in to the contracts. I have participated in this process and it makes things so much easier. Pretty much every payer has an unlisted codes policy which explains the procedure for submission. You have to fill in the narrative field on the claim.

Also, depending on your practice, there are better ways to work on cash flow and timely payment. If he knows most patients require unlisted CPT ahead of time, you can create a process for it. Are all of the unlisted procedures even covered by the payer? Are they unlisted and also invesitgational/experimental as found by the payers? What is the CPT frequency of the unlisted codes and how many unlisted codes are being used? Does your clearinghouse often reject them? If you find they are not covered/invesitgational, you would want to have a process where the patient signs something like an ABN before the procedure so you can collect payment up front. Does your practice routinely collect deductibles, coinsurance, co-pays at the time of service? Do you do pre-treatment estimates and auth and collect the estimated amount ahead of the surgery? Do you offer something like care credit, etc.? Is this clearly explained to patients ahead of time? Does the provider dictate in a timely manner so you can get claims out quickly? How fast are your EOB/ERA posted? All of these rev cycle processes can speed up the cash flow despite the unlisted code issue. This would be a better thing to look at than the process suggested above.

Here's how you do the Fax PWK for Medicare:

Here's an Anthem example (not FL but an example)
 
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Is this one Unlisted Procedure that is being performed regularly? Or is it a mix of different Unlisted Procedures?

If it is the same procedure that gets performed with some regularity, I'd also encourage them to submit a CPT request to the AMA. Of course, this isn't something that will change instantly. However, the more providers who perform this procedure and request a specific code, the greater the likelihood that one day a code will be created for that procedure.

Here's the link from the AMA website: https://www.ama-assn.org/practice-management/cpt/cpt-code-change-applications
 
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