Oncology & Hematology Coding Alert

Question: Can I append a modifier to an unlisted CPT^® code? I’m having trouble getting paid when I use unlisted codes and am wondering whether a modifier might help?

Michigan Subscriber

Answer: Unlisted codes don’t require modifiers because they cannot be matched to any fixed, described procedure, says Stephanie Sjogren, CPC, COC, CPMA, CDEO, CPC-I, CCS, HCAFA. For example, you cannot append modifier 22 (Increased procedural services) to an unlisted procedure code, because doing so suggests that your provider did something different or extraneous from a specific procedure. Such things are never defined in an unlisted code descriptor.

Instead, when you use an unlisted procedure code, it is essential you provide clear and detailed documentation describing the procedure or service performed. This may include a comprehensive summary of the intervention, the rationale for its use, the equipment or materials involved, and any complications or specific circumstances surrounding the case.

Sometimes, coders can successfully achieve reimbursement by creating a sort of crosswalk between the unlisted code and a code that describes a similar service. You may need to query your provider for the details necessary to illustrate your usage of the code and the services performed.

You should use unlisted procedure codes only when no existing code accurately reflects the specific service or treatment provided. The use of unlisted codes may require additional approval from insurance companies or other payers, and there could be challenges in obtaining reimbursement for these services. Therefore, it is important for providers to thoroughly document the procedure and for billers to maintain open, transparent communication with payers to obtain appropriate reimbursement.