Neurology & Pain Management Coding Alert

Keep encounter explanations simple, but thorough.

Filing for “unlisted” procedures might be your least favorite claims to submit because you’re not expecting much in return, but you’ll improve your payment odds and your bottom line with the field-tested tactics that follow. 

Tip 1: Use Plain English

Whenever you file a claim using an unlisted procedure code (such as 64999, Unlisted procedure, nervous system), include a separate cover letter that explains exactly what the provider did – in straightforward language. You might want to include diagrams or photographs to better illustrate the procedure. Some groups ask physicians to highlight or make notes on the actual documentation of services to indicate any description of the procedure performed. Any notes regarding the time, effort, and equipment necessary to provide the service will boost your chances of getting the claim paid.

Example: According to CPT^® Assistant, you should report spinal hardware injections with 64999. Appropriate explanatory notes from your provider might read, “The patient’s spinal surgeon has requested these diagnostic injections to determine whether the implanted metal hardware is the source of the patient’s persistent postoperative back pain. Spinal hardware blocks are performed by injecting a small amount of local anesthetic alongside each of the pedical spinal screws that were placed in each vertebrae during the patient’s previous spinal fusion surgery. If the patient’s pain is temporarily relieved by the injection(s), it may indicate that the spinal hardware is contributing as a source of the patient’s continuing pain. These diagnostic injections are used to determine whether which, if any, of the spinal pedicle screws should be surgically removed.”

Tip 2: Explain Why ‘Unlisted’ Is Necessary

Include information in the cover letter to your claim explaining why the provider is using the unlisted code.

Example: “Based on the Instructions for Use of CPT^® Codebook – ‘Do not select a CPT code that merely approximates the service provided.  If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.’  I have found that currently no CPT^® code exists for spinal hardware injections, consequently I am compliantly submitting 64999 - Unlisted procedure, nervous system for my services provided to your insured.  In addition, both the April 2011 and May 2012 issues of the AMA CPT^® Assistant publication, direct providers to report this code for spinal hardware injections.”

The provider would substitute the appropriate unlisted code and descriptor as well as any published reference regarding compliant coding for the various unlisted procedures, says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. 

For instance, an explanation for dry needling might include, “…consequently I am compliantly submitting 20999 Unlisted procedure, musculoskeletal system for my services provided to your insured.  In addition, the September 2003 issue of the AMA CPT^® Assistant publication, directed providers to report this code for dry needling.”

Tip 3: Include a Reasonable Comparison

Insurers consider unlisted procedure claims on a case-by-case basis. 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.

Tip: Don’t let the insurer determine which CPT^® code is the “next closest” for your physician’s service.

Example: Your physician administers a ganglion impar injection. Some physicians compare the injection of local anesthetic to 64450 (Injection, anesthetic agent; 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). 

Tip 4: Stick With a Single Unit

Because the unlisted codes don’t have valuations, bill with a maximum of 1 unit of service.

Support: According to the April 2001 CPT^® Assistant, “… When performing two or more procedures that require the use of the same unlisted code, the unlisted code used should only be reported once to identify the services provided. This is due to the fact that the unlisted code does not identify a specific unit value or service. Unit values are not assigned to unlisted codes since the codes do not identify usual procedural components or the effort/skill required for the service…”

Tip 5: Gather Additional Perspectives

If your provider uses equipment and/or techniques for which there is no dedicated CPT^® code, you may be able to enlist the manufacturer’s aid to receive appropriate reimbursement.

Here’s why: Manufacturers often maintain free information, resources and help lines to advise physicians on how to approach insurers regarding new technologies. Use caution when applying manufacturer suggestions, however, because you are responsible for the accuracy of your claims. You should never misrepresent a claim to gain a payment.

Insurer clearance: Some private or third-party payers might not want to handle claims with unlisted codes. If you aren’t sure whether the payer will accept a claim, talk with your representative and get any clearance in writing. Include a copy of their approval when you submit the claim.

“If pre-authorization is necessary, it’s best to establish coverage for the specific unlisted code at that point,” Hammer suggests. “It’s also helpful to have the comparative code available for reference at pre-authorization.”

Bonus: Medical specialty societies might also be able to offer guidance or supporting information about the procedure your physician performed.

Tip 6: Steer Clear of Modifiers

Modifiers are used 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. They can also be used to provide payers with additional details about the service.

Avoid: Do not append modifiers to unlisted procedure codes, however, because the unlisted codes do not describe specific procedures.