Using unlisted codes for a Critical Access Hospital

Gaastra, MI
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HELP!!! I work for a Critical Access Hospital and we are having trouble with unlisted procedure codes. We have received a transmittal that states that on March 2, 2010 CMS issued a memo to all Medicare contractors entitled "Critical Access Hospital (CAH) Method II Providers Notification." In this transmittal CMS states the following...

"please be advised that effective April 1, 2010 claims submitted by a CAH Method II provider containing unlisted Healthcare Common Procedure Coding System (HCPCS) Codes for professional services (Revenue Codes 96X, 97X or 98X) will be returned. The CAH Method II provider will need to determine a more specific HCPCS Code for Unlisted procedures rendered by a physician before resubmitting the claim. Providers unable to detemine a more specific HCPCS Code can contact the AMA to request a code be assigned for the assiciatedc procedure:" Reference: JSM CI
6520-10161; 03/02/10

Is anyone else out there dealing with this?


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Yes I have had this happen. It is a little troubling that they (CMS) is pretty much stating that you need to go back to the provider and ask them to compare the px they did to another like px that may have a billable CPT code. Um in my book that would not be correct coding.

Or CMS is stating to contact the AMA to create a code that better describes the px. Um pretty sure that that is not gonna happen any time soon. And what would be the reasoning for our request? "O because CMS won't pay for this unlisted px code." That probably isn't a real feasible request that the AMA will take seriously.

Our facility has reported unlisted codes and will continue, not that it is the norm. But there are instances that warrant the reporting of an unlisted code. Some of which are at the direction (parenthetical notes) of the AMA Professional Edition CPT coding book. I do not work in the BO but I am pretty sure these do get sent back to our coders for a second look and normally get unchanged, thus we just eat the charge because of no reimbursement. Don't hold me to that but I think that is what happens.

Good Luck!