General Surgery Coding Alert

Question: How do insurers determine reimbursement when I report an unlisted-procedure code? Can our practice do anything to increase or improve our reimbursement chances when reporting these codes?


Georgia Subscriber

Answer: There's no standard fee for unlisted- procedure codes such as 37799 (Unlisted procedure, vascular surgery). Rather, insurers consider such claims on a case-by-case basis. Therefore, the success of any unlisted-procedure claim depends largely on the documentation you submit with your claim.

You should submit full documentation with every unlisted-procedure claim. To improve your reimbursement chances, you should take these two additional steps, whenever possible:

1. Include a cover letter with a concise explanation of the procedure, free of unnecessary medical jargon and confusing terminology.

2. Compare the procedure to one with an existing CPT code that requires similar work and resources. This allows the payer to make an informed payment decision.

For example: CPT does not include a code to describe laparoscopic ventral hernia repair, so you should report it using 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy). But CPT does include codes to describe laparoscopic repair of inguinal hernia (49650, Laparoscopy, surgical; repair initial inguinal hernia), as well as open repair of ventral hernia (49560, Repair initial incision or ventral hernia; reducible), and you may use these codes as a basis of comparison for 49659 in this case.

For instance, you might alert the payer: "Surgeon performed laparoscopic repair of ventral hernia. This procedure is similar to, but less invasive than, open repair 49560, with postoperative care and recovery similar to that required by laparoscopic repair of inguinal hernia 49650."