• What are unlisted codes?

    Current Procedural Terminology (CPT) codes or Healthcare Common Procedure Coding System (HCPCS) Level II codes describe a procedure or service. On the other hand, unlisted codes are designated for services or procedures that are not otherwise specified, that is, they do not describe a procedure or service. Unlisted codes or “Not otherwise specified” codes allow medical coding companies to help physicians report and track services and procedures that do not have a specific CPT code. Reporting the unlisted code correctly with appropriate documentation allows physicians to bill and receive reimbursement even for a procedure that does not have a specific CPT code. Examples of 2018 unlisted codes in orthopedics are:

    • 27299 Pelvis/hip joint surgery
    • 27599 Leg surgery procedure
    • 27899 Leg/ankle surgery procedure
    • 28899 Foot/toes surgery procedure
    • 29799 Casting/strapping procedure
    • 29999 Arthroscopy of joint

    Correct coding requires that the code reported accurately represents the service provided, and not using a code which actually represents another service.

  • Frequently Asked Questions
  • What are the circumstances in which unlisted codes can be used?

    Physicians should never use a CPT code that does not adequately describe the service provided. If it has no specific CPT code, the service should be reported using the appropriate unlisted procedure or service code and adequately documented in the medical record. With regard to the unlisted procedure code, the American Medical Association (AMA) states: A service or procedure may be provided that is not listed in the most current edition if the CPT codebook. When reporting such a service, the appropriate ‘Unlisted Procedure’ code may be used to indicate the service, identifying it by ‘Special Report’. Unlisted procedure codes should be reported only if there is no existing CPT Category I or Category III code to describe the procedure that the physician wants to report.

  • What are the documentation requirements for unlisted codes?

    When using an unlisted procedure code, the physicians should provide a special report or documentation to describe the service. Payers deny claims billed with unlisted procedure codes without narrative information and/or supporting documentation. Claims should be submitted with the following supporting documentation and details:

    • A clear description of the nature, extent, and need for the procedure or service.
    • The patient’s diagnosis and risk of complications.
    • 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.
    • Time, effort, and equipment necessary to provide the service.
    • The number of times the service was provided.
    • What was found during the surgery (e.g., the size and location of the lesions).
    • Any other problems that the patient has and the follow-up care will be provided.
    • For unlisted surgery codes, a reasonably comparable service code/procedure should be provided as well as value in comparable RVU and/or percentage of a reasonably comparable CPT.

    The portion of the report that identifies the test or procedure associated with the unlisted procedure code must be legible and clearly marked. It may be also important to indicate why it cannot be addressed with the standard coded CPT procedures.

    The documentation requirements for different types of unlisted procedures are as follows

    • Surgical procedures: Operative or procedure report providing the nature and extent of the patient condition and detailing the work involved in the procedure
    • Radiology/imaging procedures: imaging report
    • Lab and pathology procedures: Lab or pathology report
    • Medical procedures: office notes and reports
    • Unlisted HCPCS codes: operative or procedure note
    • Clinic notes to support medical necessity

    Common attachments also include published articles and clinical information supporting the efficacy of the procedure, a cover letter and a discharge summary. All attachments should be sent with the original claim based on payer rules.

  • Can multiple unlisted codes be reported?

    If the physician performs two or more procedures on the same anatomic location that require the use of the same unlisted code, the unlisted code should be reported only once to identify the services provided. If two or more procedures that require an unlisted code are performed on different anatomic locations, the unlisted code may be reported for each different anatomic location.

  • Do unlisted codes require modifiers?

    A modifier should not be appended to an unlisted code. As unlisted codes do not describe a specific service, they do not require modifiers. However, unlisted codes for DME, orthotics and prosthetics require the appropriate NU, RR or MS modifier.

  • Is prior authorization necessary for unlisted codes?

    Getting prior authorization from the payer before performing an unlisted procedure is important to get reimbursed for elective cases. The prior authorization request should be submitted on the payer’s form designated for this purpose which will allow the physician to describe the planned procedure in detail and the medical necessity. If the unlisted procedure is performed without prior authorization (such as an urgent operation), a copy of the operative report should be submitted, along with information to support the decision-making process and the medical reasoning for performing the operation.

  • What are the steps involved in billing unlisted codes?
    • Obtain the appropriate billing instructions from the payer (whether electronic submission is accepted or if paper submission is required)
    • Obtain preauthorization
    • Select a procedure and code that is comparable to the unlisted procedure performed. This code should represent a procedure on the same body area.
    • Document the factors which make the unlisted procedure the same work, or more or less difficult than the comparison code
    • Use a percentage to indicate the difference in work between the unlisted procedure and the comparison code.
    • Indicate the normal fee for the comparison CPT code and indicate the fee for the unlisted CPT code based on the percentage of more or less work required and describe this in the documentation

Reporting unlisted CPT codes with appropriate documentation and in accordance with payer rules is critical for reimbursement. Outsourcing medical billing and coding to a reliable service provider can ensure reporting of unlisted CPT codes appropriately as well as follow up with payers if claims are denied.