Billing for Services Not Listed in CPT
April 18th, 2018
It happens to most providers. They provide services that do not meet the exact definition of a CPT code.
When compiling each year’s Current Procedural Terminology (CPT), the American Medical Association recognizes this reality and provides multiple methods for reporting services that fall outside of any CPT code’s exact definition.
The first tools a coder should review when reporting such services are modifiers. Some modifiers that may assist include:
- 22 Increased Procedural Services
- 23 Unusual Anesthesia
- 52 Reduced Services
- 53 Discontinued Procedure
Next check if there is an add-on procedure or a category III code that covers the procedure. (Category III codes are temporary codes that represent emergent or experimental services, technology, and procedures.)
When a modifier alone does not adequately change the CPT descriptor language enough to accurately describe the service rendered, the AMA has included in each section of CPT an unlisted procedure code-- usually ending in 99 and at the end of the section--that should be used to identify unlisted procedures. A full listing of unlisted procedure codes also appears in the “Surgery Guidelines” portion of CPT®, prior to the 10000-series codes
Unlisted code do NOT:
- Include descriptor language that specifies the components of the service; nor
- Have RVU values assigned since they are used for services outside the norm when work (effort or skill), practice and malpractice expense have not been established.
The following is general advice on reporting such services. Always check with your carriers for any variations that may apply.
As an example, several years ago one of our clients began implanting leadless pacemakers. Although Medicare had agreed to pay for these experimental services, the device had not received FDA approval (nor had it been grandfathered), and thus did not have an associated code. After using the unlisted code for several months, we received IN WRITING guidance from our local carrier to use a standard pacemaker CPT codes to report leadless pacemakers since the carrier was paying based on the value of the standard codes. We were to include in the descriptor field “Leadless Pacemaker” to differentiate from a standard pacemaker.
Thus, the Medicare carrier actually requested the use of a standard code for an unlisted procedure to simplify their processing of the claims.
Absent specific written guidance from your carrier, the AMA’s CPT Assistant offers these instructions for using unlisted codes:
Unlisted codes do not describe a specific procedure or service, so when using these codes, it is necessary to submit supporting documentation (e.g., an operative report, office notes) when filing the claim. This report is included to identify the specific information regarding the procedure(s) identified by the unlisted code. Relevant information should include an adequate definition or description of the nature, extent, and need for the procedure or service, as well as the time, effort, and equipment necessary to provide the service. The information may also include:
1) The specific service performed (including any assistance necessary to carry-out the service)
2) Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening
3) The number of times the service was provided, and
4) Any extenuating circumstances which may have complicated the service(s) or procedure.
To assist the carrier in pricing the procedure, KLA suggest that you include in your request for payment a comparison to a CPT code or codes that approximate the RVU value of your service with an explanation as to why your service requires the same RVU.
When performing two or more procedures that require the use of the same unlisted code, the unlisted code used should only be reported once to identify the services provided.
Carriers are divided as to whether these claims should be submitted electronically.
An unlisted procedure code or NOC must have a concise description of the services rendered in Item 19 on the CMS-1500 claim form or electronic equivalent. If you use the word “unlisted procedure” in this field, your claim will likely be denied.
If submitting electronically, be sure to include the operative report and/or office notes and the RVU computation explanation as an attachment to the claim. Otherwise the claim will be considered unprocessable. Most carriers do not afford unprocessable claims filing status so these claims cannot be appealed. (This could be critical for carriers with short appeal windows.)
The Centers for Medicare and Medicaid (CMS) addresses unlisted procedures in transmittal 1657.
Billing for unlisted drugs is beyond the scope of this post. However, the following J codes may be of help.
- J3490 - Unclassified drugs
- J3590 - Unclassified biologics
- J9999 - Not otherwise classified, anti-neoplastic drug
Please note that most carriers apply different policies to compounded medicine and most require preapproval for the use of such drugs.
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