Neurosurgery Coding Alert

Take this advice to ease the burden of billing for unlisted codes.

Unlisted codes are seen as a last resort for good reason - they are often difficult to get paid. However, there are a couple of steps you can take to optimize the likelihood that you will be satisfactorily reimbursed for the procedure you or your provider performed.

Follow these expert steps on how to submit successful unlisted procedure code claims:

1. Submit Proper Documentation

"Depending on the insurance company, you might have the option to submit the claim on paper, rather than electronically," says Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center's Department of Otolaryngology in Rochester, New York.

"If a claim must first be sent electronically, it will often be denied awaiting additional documentation. That's when the operative note and, possibly some previous progress notes, are mailed to the insurance company. However, if the insurance company allows for paper claim submissions, you may want to send the original claim out on paper to avoid the process of appealing an inevitable denial," Quinlan emphasizes.

Billing out for unlisted codes are notoriously frustrating for this reason, in particular. Without backing up your claim with documentation, you allow the insurance companies to either deny the claim, or worse, reimburse you at a level that does not document the extent of the work performed.

Experts recommend that you send claims electronically first, even when sending them via paper along with the operative note and progress notes. This is because only the electronic claim receipt will prove timely filing. Indicate on the paper claim submittal the following: "Documentation Copy, Already Submitted Electronically, Not a Duplicate Claim."

2. Submit Justification for Code

Submitting documentation of the procedure alone is not enough. Additionally, you will want to explain why the procedure at hand cannot be billed out with an established CPT^® code. This will involve comparing and contrasting similar procedures and outlining the extent of work the physician performed. For your best shot at appropriate reimbursement, you will want to submit an established CPT^® code that most accurately reflects the extent of work performed by the physician. Ideally, the insurance company will reimburse the provider using a similar fee schedule to that of the comparison CPT^® code.

"That's because you want to give the payer a reference for valuing the service," explains Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, New Jersey. "It is best to give them a CPT^® code to compare it to along with an estimated percentage comparing the work done between the established CPT^® code and the unlisted code."

Remember: When submitting to Medicare, you will want to place this information, and any other material for justification, in box 19 of the CMS1500 Claim Form.

While billing for an unlisted code is not common practice in the field of neurosurgery, it's important to understand the necessary measures required to maximize your chance at proper reimbursement. In a future issue, we will cover the different scenarios in which billing out using an unlisted procedure code is the only correct option.