Overview
This episode discusses strategies for successful billing, coding, and reimbursement of unlisted medical procedures, highlighting documentation requirements, payer-specific processes, and fee-setting considerations to maximize payment and reduce denials.
Understanding Unlisted Procedure Codes
- Unlisted codes are used when no existing CPT or HCPCS code accurately describes the procedure performed.
- Proper reporting of unlisted codes requires a concise procedure description and supporting documentation.
- Misconceptions exist that unlisted codes will never get reimbursed, but appropriate submission can result in payment.
Documentation and Submission Requirements
- Submit unlisted procedures on the standard CMS 1500 claim form, electronically or by paper if allowed.
- Obtain prior authorization for elective procedures when possible, even for unlisted codes.
- Include operative report, cover letter, certificate of medical necessity, discharge summary, and supporting rationale with the claim.
- Use Box 19 for a concise description (17 characters paper, up to 80 characters electronically).
Payer-Specific Considerations
- Check payer-specific requirements for unlisted codes; top payers may have unique processes.
- Maintain a spreadsheet and written process for tracking payer rules and update compliance manuals accordingly.
- For Medicare, documentation must be sent to the local Medicare Administrative Contractor (MAC).
Fee-Setting Strategies for Unlisted Codes
- Select a comparable CPT code in the same body area to estimate fee for the unlisted procedure.
- Document comparison factors: approach used, operative time, difficulty, and percentage difference in work.
- State both the fee for the comparison code and the proposed fee for the unlisted code, justified by documentation.
Tips and Common Scenarios
- Always verify if an appropriate code exists before using an unlisted code.
- Avoid billing an existing code and an unlisted code for the same procedure on separate lines.
- For new or unusual procedures, inform your MAC advisory committee to facilitate future claims.
Special Procedures and Techniques
- The need for unlisted codes often arises when technique differs (e.g., laparoscopic vs. open approach) and no specific code exists.
- For robotic surgery, use standard surgical codes unless a unique procedure code applies.
Decisions
- Rely on thorough documentation and comparison codes to substantiate fees and medical necessity for unlisted procedures.
Action Items
- TBD – Coding/Billing Staff: Update compliance manuals and payer tracking spreadsheets to reflect current unlisted code processes.
- TBD – Coding Staff: Ensure complete supporting documentation and concise descriptions are included with all unlisted procedure claims.
- TBD – Surgeons/Offices: Contact MAC advisory committees about new unlisted procedures for ongoing education and future efficiency.
Questions / Follow-Ups
- Clarify payer-specific requirements for top private and government insurers regarding unlisted codes.
- Determine if new codes are introduced for previously unlisted procedures in each annual CPT update.