Anesthesia Coding Alert

Documentation:

Follow These 4 Steps to ‘Unlisted Procedure’ Success

Published on Wed Sep 15, 2021

Keep your supporting documentation simple but clear.

Every coder wants to be as specific as possible when reporting their providers’ services, but sometimes you have no option other than submitting an “unlisted procedure” code. When you find yourself in that situation, follow these four steps to increase your chances of receiving adequate reimbursement for the service.

Step 1: Keep It Simple

If you report pain management services, you can find yourself turning to code 64999 (Unlisted procedure, nervous system). Be sure to include a separate cover letter with the claim that explains what your provider did — in easy-to-understand “real world” terms rather than lots of medical jargon.

Pro tip: Ask your provider to highlight or make notes on the procedure documentation that help explain the service (especially anything related to the time, effort, and equipment necessary). Including illustrations or diagrams can help paint an even clearer picture of the service.

Step 2: Explain Why ‘Unlisted’ Is Best

Insurers want to know why your claim doesn’t include a standard CPT^®code specific to a procedure, explains Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPMA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. Get the facts from your provider and include this information in the cover letter.

Pain management example: Reporting code 64999 is more appropriate for an erector spinae plane (ESP) block than a code such as 64461 (Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)). An explanatory note could include information such as, “ESP blocks involve injecting anesthetic into the musculofascial plane between the paraspinal back muscles and underlying thoracic vertebrae. The ESP block targets the tips of the transverse processes and is categorized as a paravertebral block, or PVB. A PVB targets the sympathetic chain of nerves and somatic nerves (intercostal and spinal nerves and their branches), from T2 to L1. The erector spinae is a group of muscles and tendons extending the length of the spine (and on both sides). This is not a separately identified spinal nerve or branch, so an injection code specific to a certain nerve or branch of nerves is inaccurate.”

Anesthesia example: Your provider administered general anesthesia during a patient’s EEG because of the patient’s diagnosis of autism and the potential for behavioral issues. Include this patient-specific information in the cover letter and a primary diagnosis of the behavioral or autistic disorder (such as F84.0, Autistic disorder) to help justify the need for anesthesia and your use of 01999 (Unlisted anesthesia procedure(s)).

Step 3: Compare to an Established Code

Because “unlisted” codes are catch-all codes that can apply to many procedures, they are not assigned a reimbursement value. Now that you’ve explained about the procedure your provider performed, you need to demonstrate its worth in terms of potential reimbursement.

Any payment you receive will be based on comparing your procedure description to a similar, valid CPT^®procedure code with an established reimbursement value. This comparison code should be similar in physician work, malpractice risk, and practice expense when compared to the unlisted procedure.

Don’t let the insurer determine which CPT^®code is the “next closest” for your physician’s service, Dennis warns. Provide that information yourself.

Example: Your physician administers a ganglion impar injection. Some physicians compare the injection of local anesthetic to 64450 (Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch). If he performed nerve destruction instead of administering a temporary numbing agent, you could compare the destructive procedure to 64640 (Destruction by neurolytic agent; other peripheral nerve or branch).

Caution: Some coders are tempted to report 64520 (Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)) for a ganglion impar injection, but that choice is incorrect. “CPT^®is explicitly clear that ‘close’ is not appropriate when determining the code to report,” says Marvel Hammer, RN, BS, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver. “Code 64520 is for a lumbar or thoracic sympathetic block, whereas the ganglion impar is located in front of the coccyx. It’s obviously not the same anatomic location.”

Pro tip: Medical specialty societies such as the American Society of Anesthesiologists might be able to offer guidance or supporting information about the procedure your physician performed.

Step 4: Remember Single Unit, No Modifiers

Because the unlisted codes don’t have valuations, you don’t need to calculate units as with some other services. Instead, you report the unlisted code once on the claim with a maximum of one unit of service.

You also should no report modifiers in conjunction with unlisted codes.

Here’s why: Modifiers are added to a claim to indicate that the service your provider performed was altered a bit from the specific CPT^®code descriptor, but not changed from the basic service. Modifiers also can be used to provide payers with additional details about the service. Because unlisted codes do not describe specific procedures, appending a modifier is inappropriate.