[Music] welcome to the codcast podcast real world insights for your daily medical coding and billing processes and now here's your host Terry Fletcher hello everyone and welcome to the codcast podcast today my name is Terry Fletcher today is our 329th episode so I'm pretty excited about that and I'm gonna bring up a topic that I actually have never talked about before but it's come up a couple times in the last week or two so I thought maybe it's time to talk about it and that is unlisted procedures and I just want to give you maybe some strategies or insight for successful billing coding and reimbursement because I know that's definitely a tough topic The Code cast is brought to you today by select coder get all the decision-making information you need to code in a single online resource select coder offers you the comprehensive coding guidance required to code accurate claims the first time learn more about select coder visit coding books.com select coder okay so let's talk about unlisted procedures so the um American College of Surgeons put out a great bulletin in 2017 and then they updated it in 2023 and so I'm referencing that a little bit and also my um my CPT or I'm sorry my yes my CPT manual but also the the CMS uh Medicare claims processing manual chapter 26 and so there's a lot of reference material in front of me as I'm talking about this but when seeking reimbursement for a surgical procedure first of all you do have to make sure that you have you look to see if there is a CPT or hick piix that already accurately Andor precisely describes the services provided but CPT also has has in their directions for use in the Roman numeral section it says if no CPT or hick piix code exists then report the procedure uh using an appropriate unlisted CPT code so I know some coding staff and even surgeons are under the misconception that unlisted codes mean you're not going to get paid I've even heard people tell me at an APC conference I was speaking at well that never works well never is a long time so let's kind of take a step back a bit and really figure out how can we get this paid and what would be the best um Avenue to go to to try to get this paid so CPT codes especially when that's an unlisted code when reported with appropriate documentation should be reimbursed and it's really going to be the responsibility of the coding and billing staff I I don't don't like to put this on the surgeon because this is our responsibility to report unlisted CPT CPT codes appropriately and then follow up with payers if you get a denial and also if it's delayed so we want to really look at first of all what are the reporting requirements so it should be reported on the standard 1500 hicka form we know that and most payers require that CMS standard form and you either have to submit it electronically um in the best case scenario uh some will still allow you to to um send it in by paper but not very often but reporting an unlisted procedure requires more steps than just putting unlisted code on the claim so you're going to have to do some things before and after the procedure than just reporting it so to lessen your chance of payment denial for elective cases it's best to obtain prior authorization yes even for an unlisted code most payers have a prior authorization form that does allow your office your surgical office to describe the plan procedure and the medical necessity of the operation also remember with the no surprise act surprises Act you actually have to have how much this is going to cost the patient out of pocket anywhere at least anyway at least an estimate of that and so you you really need to um at this point follow up with that and try to start the process in this in this way so in those instances where an unlisted procedure is performed without prior authoriz authorization for example if it's um an urgent operation or an unanticipated interoperative procedure that doesn't have code a copy of the operative report is going to have to be submitted along with supporting information outlining the decision-making process and the medical rationale for performing the operation that's a really big thing why did you do it for Medicare patients this documentation will be have will have to be submitted to the m carrier which is the Medicare administrative contractor so your local Medicare provider individual payers they may have their own processes in place for unlisted codes make sure you check because I know ET and and United Healthcare both do it's also important to be familiar with your top payers and what their specific processes are to help expedite the claim and make yourself a spreadsheet that's what we had to do with tella Health that's what we have to do with certain g-codes I mean because some of those g-codes are actually paid by U private insurance companies so we just want to make sure what everyone's procedure is and hopefully you have a specific process but make sure that once you've figure out a process and you can have Medicare and then everybody else you probably will have Medicare Medicaid and then everyone else um that you have a written process and that it's in your compliance manual when submitting an unlisted procedure you need to have a concise description of the procedure and that's what box 19 is for that's a remarks box on the CMS 1500 paper form or the electronic media claim form so this is a concise statement um so if it's paper you're only getting up to 17 characters if it's electronic you get up to 80 characters or sometimes less uh even if the description can be summarized in this small space you're still going to need those additional claim attachments so it could be a cover letter um it could be a certificate of medical necessity and a lot of the private plans have those uh a discharge summary and of course the most important the operative report so these attachments are sent with the original claim either electronically um by fax or email does anybody really take facts anymore but or hard copy based again on the payers rules there are still payers out there that will take hard copy but now they're charging for it and then after the claim is been submitted you want to make sure you're waiting for that eom or explanation of benefit from the private plan to see if they paid you hopefully what you're asking but at least as close to what you're asking as possible so how do you fee set which brings me to money so fee setting considerations for unlisted Cod codes are really tough T so your charge for the unlisted procedure is included in 24f of your claim form to support your charge I recommend that you attach that cover letter and here are kind of the steps you want to take first of all choose a comparison code it needs to be similar to the enlisted procedure code it should represent surgery on the same body area so for example you may choose the CPT code let's say for open partial gastrectomy as your comparison code for a part paral gastrectomy conducted using a laparoscopic approach each organ system and or the body area selection uh section of the CPT manual has an unlisted code that corresponds to an unlisted procedure in that organ system and or body area it's right at the end then you want to list two or three factors that make the unlisted procedure the same work or close to the same work or it could be more or less difficult than the comparison code but that should be documented so for example your letter could indicate that the unlisted procedure required a different operative approach and approximately 35 to 40 minutes of additional operative time than the comparison CPT code I know this kind of sounds like a 22 modifier but it's not because a 22 modifier means an existing code was increased this means you don't even have a code for it then the the third you know part of this consideration is that indicate the difference in work between the unlisted procedure and the compar code using a percentage so for example you may estimate that the unlisted procedure required 50% more time for exposure exploration and closure than the comparison CPT code was and it was scheduled that way so you always want to throw that in there too on how you scheduled it because they're going to ask for the scheduling record I guarantee you and then indicate the normal fee for the comparison code and then indicate the fee for the unlisted CPT code based on the percentage of more or less work required and documentation and also document that in your letter so for example you may indicate that your normal fee comparison code is $11,000 so you want to set your unlisted procedure at, 1500 because again we talked about that 50% more for exposure and exploration but if that's what you're saying that's what it has to be you've got to be very clear on that because the payer will call you out on it so an example um you know let's say we have a laparoscopic gastrostomy okay well we don't have a code for that so it' be 43 659 for unlisted laparoscopic procedure stomach but my comparison code would be the 4382 gastr doosy without vagotomy we don't have a lot of lap codes that are also crosswalked to the open codes and that's why I brought that up one recent one that U Med not Medicare but CPT has in the 2024 CPT book and I don't deal with fomy but there's one that they had it's fomy less than 10 stabs so the existing code 37765 is stab fcom of varicose veins one extremity 10 to 20 stabs incisions so with that you would want to report the 37799 unlisted procedure for vascular surgery because there's not a code for less than 10 stabs now somebody said well I could do a 52 modifier you could but don't you want to get exactly what you did and it's not it's the Lesser code now let's the the carrier price it instead of the physician and try not to just go to the physician and say I want you know that because they they always say I want $5,000 you can't have it so you you got to be careful with that but also let's say hemorrhoidectomies for example so there is a code 46255 for hemorrhoidectomy internal and external and but if you're just doing an hemor atomy external single then there isn't a code for that so it would be 46 999 the unlisted procedure in the anal area and then you would what what is it comparison to and so again that would be the hemor ectomy in uh internal and external external single so it's similar you you have to get as close as you can to a comparison code and it it shows them you're doing your work so um if you're it's really hard when you're not giving them a comparison code because again then you're leaving it up to the payer for Medicare patients the unlisted procedure performed is one that other surgeons may also perform in similar clinical circumstances it would be helpful to share this information with the surgical representative um on the Medicare contractor advisory committee that's called the CAC because this exchange provides the opportunity to inform and educate your Mac medical director so you know they know that there's a new procedure that future cases may need to be reviewed and processed more efficiently and a lot of the Mac carriers can add their own code uh specific to a procedure so eliciting the support of the surgery again advisory committee of the Medicare contractor so that representative provides you with the opportunity to establish those open lines of communication with that Medicare medical uh contractor of that Matt carrier and to discuss coding and billing issues as they come up including changes and updates in payment and other pertinent information between the contractor and again the medical community not just coding and billing but now the physician has a relationship and your office has a relationship keep in mind that the percentage indicated in step three that's really important because although the payer will adjust up or down from its fee schedule not the physician's charge they're going to adjust based on the allowable but then also make sure you're first checking to see if there is actually a code for what your physician did did because when reporting an unlisted code to describe a procedure or service you have to submit supporting documentation along with the claim you have to give an accurate or I should say an adequate description of the nature extent and need for the procedure and the time effort and equipment necessary to provide the service and also look on the look inside the chapter 26 of Medicare claims processing manual there's information there also on how to submit an unlisted code to Medicare but the biggest thing thing is that and where you'll see denials is that it's not when you build an unlisted code on one line item and that's it it's when you try to bill for a code that exists and then try to put unlisted code on separate line items I've seen that happen quite a bit and the carrier usually will deny saying it's inclusive of the primary procedure how I don't know I'm not saying how to get around it but how to explain that is if it's not routine so if it's something that's not inclusive of this procedure or let's not routinely done with this procedure then it would not be considered incidental remember when we had um the um the Minal menisectomy and cond plasty before we had a cond plasty Cod a lot of people would put unlisted now I'm going back 20 years but then they came up with a cond plastic coat and then everybody was coating it all the time with that with a 59 and remember the 59 means distinct procedural service that rarely happens and now it's with or without condra plast now they're bundling it so to to not have to deal with the bundling issues especially for unlisted codes make sure that's part of your documentation that this particular example doesn't exist and it's not something that uh we do very often now when it comes to robotic surgery robotic surgery does have uh code specific to that now in 2024 but also many of the descriptors uh in the directions for use in that chapter will will say to use just a regular surgical coat so that's not where you go into the unlisted please don't use it for that but if it is a separate procedure where you just don't have a code for it example laparoscopic internal hernia repair so we have a reduction of volvulus um of the internal hernia by laparotomy but do we have a specific that not yet so we would have to code the unlisted 44238 instead of the 4405 so we don't always have a specific code and you notice I use lap again because one of the biggest issues I'm finding with unlisted is technique is that we may have an open code but we don't necessarily have laparoscopic endoscopic or the certain tools we're using to perform the surgery and that's when it does become um now a unlisted code The Code cast podcast is also brought to you today by the Netflix Siri The Lincoln Lawyer check out seasons 1 and 2 on netflix.com and look for season 3 to drop in Fall 2024 The Lincoln Lawyer is based on Michael Conley's book The Gods of guilt the third season of The Lincoln Lawyer will have 10 episodes I can't wait for that because one of my favorite shows I've actually still started watching it over and over so I appreciate uh them sponsoring our one one of our sponsors today for our Code cast so part of the my that could have been my personal tidbit but since we are now in February it is my daughter's birthday this month so quick shout out to her so Sumer happy birthday it's next week and also for those of you that are watching the Super Bowl I'm not sure who you're rooting for is it going to be 49ers or chiefs I don't know so we'll I guess we'll find out and uh I'll talk a little bit about it just even just to mention it on our next episode but we'll see I know I'll be watching I'm bummed it's not my Steelers but I am a football fan so we'll see what happens all right everyone hopefully you are having some decent weather as we saw that the groundhog said that we are going to get an early spring did not see his shadow so there you go so make it a great day make it a great rest of your week and thank you for listening to the codcast podcast for more information on medical coding billing auditing and compliance including how to hire Terry follow Terry on Twitter at Terry coder1 or visit her website at www. 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