Anesthesia Coding Alert

Start-to-finish steps to help your claim pass muster

Following tried-and-true coding methods is one of the best ways to get adequate reimbursement for unlisted pain management procedures. Check off these four steps the next time you're faced with reporting 64999 (Unlisted procedure, nervous system) for a myriad of procedures.

Step 1: Be Sure It's Covered

First, call the carrier to be sure the service is a "covered service." Tell the carrier up front that this is an unlisted procedure and that you'll submit the claim with backup documentation.

"It's always better to know up front if the service won't be covered so the provider and patient can make an informed decision about whether to proceed," says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. "It's more difficult letting the patient know after the procedure that a diagnostic (non-therapeutic) procedure is denied by their insurance and now they are responsible for payment."

Step 2: Get the Details

The operative notes should describe the procedure in detail, but include a "Cliff Notes" version in the cover letter that is less "medical-ese" and simpler for the carrier representative to understand.

Encourage physicians to document medical necessity for this specific service or procedure, including any successful and unsuccessful diagnostic or therapeutic procedures to treat the patient's pain.

"Carriers are looking for the reason to support the concept that the procedure is potentially standard of care and not experimental - CPT just hasn't created a code for it yet," Hammer says. "If the procedure is 'on the outskirts' of standard of care, then include how this service has the potential to be cost-effective."

Example: Administering botulinum injections to relieve the patient's headaches = decreased patient visits to the ED = decreased costs to insurance.

Step 3: Compare Codes

Compare the unlisted procedure to an existing CPT procedure code, and review the accepted charges to help capture appropriate reimbursement for the unlisted procedure. The comparison code should ideally have similar work, practice expense and malpractice risk values to the unlisted procedure in question. You're not required to use a comparison code that describes a similar procedure to the one you're submitting, but it can help the carrier's understanding.

Step 4: Get Help from Others

Don't be shy about searching out other opinions on how to code and bill the unlisted procedure. Equipment vendors, manufacturers and physician specialty societies use outcome studies to document the validity of a procedure. These groups can suggest codes to consider, although you should always carefully check their suggestions to be sure the recommendation is correct and compliant. Also verify that any codes they recommend are not bundled with other procedures through NCCI edits.