Health Information Management

Perform due diligence before assigning unlisted codes and take additional steps when reporting them

JustCoding News: Outpatient, July 14, 2010

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by Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA

When a provider cannot find a specific CPT® code to accurately reflect a procedure or service, coders may report unlisted codes, which are included throughout each section and subsection of the 2010 CPT Manual and usually end in “99” (e.g., code 59899 in the maternity care and delivery section).

Physicians sometimes perform procedures that are not accurately captured with standard listed codes due to a patient’s altered anatomy, such as a trauma, burn, or some other medical reason.

Coders should only report unlisted codes for a test or procedure as a last resort. This does not mean you should never use them. But make sure you’ve done your due diligence to investigate and determine that there is no other code that more appropriately reflects the procedure or service.

This is especially important for surgical coders and billers to understand, as CMS does not assign any relative value units to unlisted codes. Many of the unlisted CPT codes are grouped to ambulatory payment classifications with little or no reimbursement.

It may be tempting to report a code that is a close description of what the physician documented. However, just because you identify a code that closely matches the procedure or service does not mean it is the correct choice.

When reporting an unlisted code, check to make sure that you don’t overlook reporting an appropriate Category III code. You may discover that there is a Category III code for emerging technology that you can include with your unlisted code.

Be sure to carefully read what is actually in your physician documentation or operative report. Don’t just assign codes from the operative report headings; review the entire operative record. You may discover that the physician truly performed a procedure for which there is a listed CPT code, and you simply need to append a modifier (e.g., modifier -52 for a reduced service, modifier -53 for a discontinued service). Click here to view two coding examples.

If there are additional procedures performed in the same operative session, for which specified CPT codes are appropriate, also include those codes on your claim.

The 2010 CPT Manual also includes unlisted codes for evaluation and management (E/M) services. Providers may use these unlisted E/M codes for services such as an intraoperative consultation between surgeons and physicians in the operative suite or giving medical clearance for athletic competitions or travel to foreign countries. Click here to view a coding example.

Next, you must determine the appropriate amount to charge for this unlisted service. Discuss with your physician the complexity of the service, the amount of time the physician spent rendering the service, and the equipment or supplies used to arrive at the dollar amount you decide to bill. Some insurance carriers request that you forward this justification with the claim.

When submitting claims that include unlisted codes, it is very common for insurance carriers or third-party payers to deny payment. CMS and most private payers will edit out the claim from further processing until you send them additional supporting documentation (e.g., the operative note, clinical study references from specialty organizations, or a letter detailing medical necessity to support the claim).

When you receive the electronic denial from the payer requesting supporting documentation, send back a cover letter with your documentation describing the unlisted procedure completely and concisely. Include a copy of the CMS 1500 or UB claim form with the unlisted CPT code, and diagnosis code(s), a copy of the operative or procedure record, and pathology report if appropriate.

Ask the carrier to adjudicate your claim within a standard timeframe (e.g., four weeks). If you do not hear back within that requested time, follow up with the payer and confirm whether it received your claim and if so, when it plans to process the claim and submit payment to you. However, if the payer did not receive your claim, ask if you can expedite the claim and forward via fax or secure e-mail.

Editor’s note: Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, is an independent consultant in Melba, ID. E-mail her at LORIWEBB@sarmc.org.



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