DOING BUSINESS


The Business of Unlisted Codes Strategies to avoid rejections, denials and audits BY JESSICA EDMISTON


Surgeons often embrace new technology and highly complex or rare cases. While these chal- lenges help surgeons excel


in their field, they also can create cod- ing and billing dilemmas. New services or procedures that do


not have an accurate, descriptive Cur- rent Procedural Terminology (CPT) or Healthcare Common Procedure Cod- ing System (HCPCS) code must be reported to payers using an unlisted code. Private payers might reimburse claims with unlisted codes, however, they might determine payment based on their fee schedule for a compa- rable procedure or other methodolo- gies. When in doubt on how to sub- mit unlisted codes with private payers, refer to your contract.


For Medicare claims, if there is no billable code you must report an unlisted code, recognizing that Medi- care will not reimburse for this pro- cedure. We understand physicians’ frustration in this regard. Using codes “close enough” to the procedure or ser- vice performed puts the provider at risk of overpayment due to misrepresenta- tion. It also puts the provider at risk of an audit and possible repayment. For commercial payers, submitting


unlisted codes without proper docu- mentation can lead to claim rejection or denial. Again, review your con- tracts to ensure you submit all required descriptions and documentation. We also recommend writing the Medical


American Association to


advocate for new procedure codes where applicable. Professional mem- bership organizations such as the American Academy of Orthopedic Surgery can do the same.


14 ASC FOCUS APRIL 2021 | ascfocus.org


For all their complexities, submit- ting claims with unlisted codes will help keep you compliant and alert to the need for new CPT codes.


Unlisted Codes: Background and Billing The CPT manual includes


codes include: ■


■ unlisted


codes at the end of each anatomy sec- tion. They usually end in a -99. Examples of orthopedic unlisted


Endoscopic cubital tunnel release: CPT 29999.


Manipulation of knee joint when general anesthesia is not used: CPT 29999.


■


Arthroscopic gluteus medius repair: CPT 29999. Claims using unlisted codes must


be accompanied by specific informa- tion about the service and/or proce- dure and supporting documentation. That documentation varies by payer.


Billing/claims staff should understand each payers’ process for submitting claims with unlisted codes. Common documentation require-


ments include: ■


a complete description of the nature, extent and need for the procedure; ■ a procedure report; and


■


a comparable service or procedure code. This information helps deter- mine a fee for the unlisted procedure. Pre-authorization may be necessary for elective procedures to ensure reim- bursement. The prior authorization process does not change when using unlisted codes but it may require addi- tional work. In addition to understanding payer processes for unlisted codes, staff must stay abreast of all CPT code changes to include additions and deletions of unlisted code scenarios. The American Medical Association revises the CPT code set annually.


The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion.


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