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Q&A: Pay attention to unlisted CPT codes

APCs Weekly Monitor, February 6, 2009

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Q. Can hospitals report unlisted CPT codes or those that typically end with “99”?

A. MLN Matters MM 6320, published December 31, 2008, comments as follows on unlisted CPT codes:

Under the OPPS, CMS generally assigns the unlisted service or procedure codes to the lowest level APC within the most appropriate clinically related series of APCs. Payment for items reported with unlisted codes is often packaged.

For non-OPPS payment purposes, when an unlisted service or procedure code is reported, a report describing the service or procedure should be submitted with the claim. Pertinent information includes a definition or description of the nature, extent, and need for the procedure or service, as well as the provider’s time, effort, and equipment necessary to provide the service.

When a Medicare contractor receives a claim with an unlisted HCPCS code for non-OPPS payment, the contractor shall verify that no existing HCPCS code adequately describes the procedure or service. Unlisted codes should be reported only if no other specific HCPCS codes adequately describe the procedure or service. If an unlisted code is submitted on a claim and the contractor has verified that the code submitted is correct, the contractor pays the claim using the unlisted code, based on the applicable non-OPPS payment methodology. However, if it is determined that an unlisted code was submitted in error because the procedure or service is described by a specific HCPCS code, the contractor shall advise the hospital (or critical access hospital (CAH)) of the appropriate code and process the claim with the correct code. If a procedure or service reported with an unlisted code is reported frequently, the contractor shall advise the provider that a request for a specific CPT code or alphanumeric HCPCS code should be made.

You can download the CY2009 unlisted CPT codes for procedures and services in zip format from CMS’ 2009 Annual Policy Files Web page.

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