ED Coding and Reimbursement Alert

 Also, CPT^® updates modifiers you can — and can’t — use with unlisted codes.

If your physician has ever performed multiple unlisted surgeries and wasn’t able to garner payment for all of them, there’s good news for you.

In a recent issue of CPT^® Assistant, the coding resource explained in detail the updated guidelines for reporting multiple unlisted surgical codes for the same patient during the same session.

Check out this rundown on all the relevant points on these new guidelines.

CPT^® Tells Coders to Consider These Rules Final

In “Understanding the Updated Guidance for Reporting Unlisted Codes in the CPT^® 2024 Code Set,” which appears in the January 2024/volume 34, issue 1 of CPT^® Assistant, CPT^® explains how its new rules for reporting unlisted procedures will affect coding. “The revised guidelines for reporting unlisted CPT^® codes remove a lot of the confusion surrounding proper reporting of these codes by setting standards to follow,” says Heidi Stout, CPC, COSC, president of Coder on Call, Inc., in Milltown, New Jersey.

The article makes clear that these are the new rules for reporting unlisted codes. “It is important to note that the guidance in this article supersedes all other guidance for reporting unlisted codes previously published in CPT^® Assistant,” it states. Before January 2024, “CPT^® convention guided users that unlisted codes should not be reported in multiple units or with modifiers appended because the procedure itself was unspecified, and it did not make sense to attempt to clarify the circumstances that would typically be identified using a modifier when appended to an otherwise unspecified procedure.”

On January 1, however, things changed. The new guidelines state that if multiple unlisted procedures are performed at the same session, each unlisted code may be reported.

“While uncommon, if multiple separately reportable unlisted services are performed on the same patient on the same date of service by the same physician or other QHP [qualified healthcare professional], then multiple unlisted codes may be reported,” CPT^® Assistant states.

This is a boon to practices, as “instead of being limited to reporting only one unlisted CPT^® code per operative session, multiple unlisted CPT^® codes may be assigned if appropriate,” explains Stout.

“When an unlisted procedure code is used, the service or procedure should be described (see specific section guidelines). Each of these unlisted codes (with the appropriate accompanying topical entry) relates to a specific section of the code set and is presented in the guidelines of that section,” according to CPT^® Assistant.

“Similarly, it is appropriate to report an unlisted code together with a Category I or Category III code(s) for the same patient encounter on the same date of service when a separately reportable portion of a provided procedure or service is not described by an existing CPT^® code(s).”

Report Same Code Multiple Times

According to CPT^® Assistant, you could also conceivably report the same unlisted code multiple times during the same session.

“If an unlisted procedure is performed on more than one anatomical region (eg, on extremities, upper and/or lower, different spinal regions, etc.), then the unlisted procedure code may be reported in multiple units to account for each region or site treated,” per CPT^® Assistant.

If you are reporting the unlisted procedure code more than once, you’ll need a modifier like 59 (Distinct procedural service) or 51 (Multiple procedures) to separate the services. “As it was in the past, it is still essential to report unlisted procedure codes in accordance with … payer policies.”

Guideline Edits Also Affect Modifier Use

Both of these guideline changes mean that you’ll be able to use modifiers to denote how you’re separating the services. Check out a rundown of the modifiers you’ll most need:

• Unlisted procedure on different sides of the body: LT (Left side), RT (Right side)
• Unlisted procedure performed bilaterally: 50 (Bilateral procedure)
• Multiple unlisted procedures performed at the same session: 51, 59
• Unlisted procedure performed by two physicians: 62, (Two surgeons)

As the situation dictates, you might need to use other appropriate modifiers to denote the special circumstance, the article states.

“However, it should be noted that payer guidelines may differ,” Stout explains.

Best bet: Check with your payer before reporting two unlisted procedure codes to see how it wants you to file the claim.

Caveat: CPT^® Assistant warns against using most of the other modifiers in the code book to report multiple unlisted procedures. “Because unlisted codes do not include descriptor language that specifies the components of a particular service, modifiers that describe alteration of a service or procedure may not be used. For example, it would not be appropriate to append modifier 52, Reduced Services, to an unlisted code,” the article states.

Do This When Comparison Coding

CPT^® Assistant directs readers to their code books in order to better understand the multiple procedure rules. “To highlight the changes, many new instructional guidelines on the proper use of unlisted codes were added throughout various sections and subsections of the CPT^® 2024 codebook, especially in the Introduction section where instructions and guidance for using the CPT^® codebook and for reporting unlisted procedures or services are included.”

The new guidelines and examples are available on pages xv-xix of the CPT^® 2024 codebook.

When reporting unlisted surgery codes, it may be necessary to provide comparison codes for the unlisted codes reported on claims submitted for payment. Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan, has advice on submitting unlisted codes that you should take to heart when considering these new guidelines.

“Because unlisted codes are manually reviewed, be as much help as you can to the reviewer. In other words, make comparisons to things they know. For example, a note from the provider giving information like ‘this procedure is most like the 33xx3 procedure because it entails doing xxxxx, which is what the 33xx3 code is.’”

Benefit: “This way there is not only something to compare the unlisted work to, but there is an additional reference with an estimate of how much work, comparatively, the remainder of the procedure was. The fee should reflect this percentage increase,” explains Young.