Getting Reimbursement for Unlisted Procedures

by | Last updated Jun 30, 2023 | Published on Aug 5, 2015 | Resources, Articles | 0 comments

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Getting proper reimbursement for unlisted procedures is not that easy and you have to follow certain steps to increase the chances of reimbursement. A proper insurance verification is the first step you need to take. If the insurance carrier considers the service you provided a non-covered one, ensure that the patient is aware of this and request the patient to call the carrier to have a better understanding on their policy regarding unlisted and non-covered services.

Even if the carrier won’t pay for the unlisted procedure, it is advisable to bill the insurance carrier. This will allow the carrier to see that you are providing the service and the EOB will probably show a ‘patient responsibility’ remark code. The ‘patient responsibility’ EOB can help patients become educated on how their carrier processes claims, which will make it easier for you to get paid directly. Insurance companies often deny payment for unlisted procedures due to ‘lack of medical necessity.’ Under such circumstances, ask the carrier to define ‘medical necessity.’ You can request a written definition and review it. It may be possible to send in a pre-authorization letter in the future.

Unlisted Procedure Codes

When you submit your claims for unlisted procedures, it is very important to assign the most appropriate medical codes that indicate the relevant procedure. You can claim unlisted procedure codes only if an existing CPT Category I or Category III code cannot describe the procedure that you want to report. According to the National Correct Coding Initiative Policy Manual for Medicare Services, it is inappropriate to report the best fit HCPCS/CPT code unless it accurately describes the service performed, and all components of the HCPCS/CPT code were performed.

Unlisted procedure codes are identified as XXX99 or XXXX9 codes and can be seen at the end of each section or subsection of the CPT codebook. A full listing of unlisted procedures also appears in the ‘Surgery Guidelines’ portion of CPT before the 10000-series codes. Be sure while reporting the appropriate unlisted code for the category/type of procedure performed.

Documentation of Unlisted Procedures

Insurers consider claims for unlisted procedure codes on a case-by-case basis and they determine payment according to the documentation you provide. Here are some documentation tips recommended by the American Association of Professional Coders (AAPC) for healthcare providers to ensure the claims are reimbursed.

  • Describe the Procedure in Plain English – Whenever you file a claim with an unlisted procedure code, include a separate report that explains exactly what you did in simple, straightforward language. You can include diagrams or photographs to help the insurer understand the procedure better. Certain practices do recommend highlighting or making notes on the operative report in order to indicate where the provider describes the unlisted procedure. Do not forget to submit the documentation of medical necessity to support the decision to perform the procedure.
  • Attach a Cover Letter – While submitting a claim for an unlisted procedure, your documentation should include an explanatory cover letter. For example, if you have performed a post-fistula tracheotomy tube change on a young child in the operating room under anesthesia due to certain circumstances and used an unlisted procedure code, you can state this as “I performed the procedure under anesthesia in the OR rather than in the office because the patient was a young child who could not be safely restrained in the office setting. This was the best method to ensure a positive outcome and prevent any undue harm to the patient. CPT does not contain a code to describe a procedure of this type, and therefore we are submitting an unlisted procedure code”.
  • Compare the Procedure – An insurer will compare your procedure description to a similar, listed procedure having an established reimbursement value to determine the payment for an unlisted procedure claim. Instead of leaving it to the insurer to decide which code is the closest, you should clearly make reference to the nearest equivalent procedure. Note the specific ways in which the unlisted procedure differs from the nearest equivalent procedure listed in CPT, which will help relate the procedure performed to an existing procedure as support for reimbursement. Though basing your fee on a similar procedure is not mandatory, it is helpful in claims processing.

When you are submitting an unlisted procedure code for a particular service, consider meeting with the payer to discuss how much you might be paid for the service that you provide without documenting extensively for each claim. The payer may create a dummy code for the unlisted procedures or set a fee for the codes to facilitate automatic adjudication.

You should adhere to AMA coding guidelines and have clear and effective communication with the payer. A professional medical billing and coding company can support you in getting reimbursement for unlisted procedures. With reliable medical coding provided by AAPC certified coders and timely medical billing and claim submission ensured by the medical billing firm, you can focus on your core activities without any concerns over the reimbursement for unlisted procedures.

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