Ophthalmology and Optometry Coding Alert

Question: We reported 92499 for a service that had no CPT^® code assigned to it but we aren’t sure what to charge or how to explain what was done. Can you advise?

Codify Subscriber

Answer: As most coders are aware, codes that are associated with specific services are assigned reimbursement values. That isn’t the case with unlisted procedure codes because the codes can potentially represent such a wide range of services. Your first step in receiving adequate payment for unlisted procedures lies in clear, detailed documentation by the ophthalmologist.

Start by including a cover letter stating why you are submitting the unlisted procedure code. This separate report should explain, in simple, straightforward language, exactly what the physician did.

Part of a coder’s job is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman’s terms. Including diagrams or photographs to better help the person reviewing your claim understand the procedure can further clarify the situation.

Expert tip:  Ask the ophthalmologist to include a paragraph at the top of the report explaining what the procedure was and why reporting an unlisted code is necessary. This lends further support to the cover letter you file with the claim.

If you’re worried that you might be overloading the payer with too much information, stop stressing. Doing everything you can to make sure your provider gets paid what you think is appropriate includes sharing the details. Claims reviewers don’t necessarily have a high level of medical knowledge, and physicians don’t always dictate the most informative notes. Err on the side of giving the payer too much information rather than not enough.

Most coders submit these claims electronically without the documentation so that they have proof of timely filing, and then send the documentation with a statement on the claim saying that this is a documentation copy, not a duplicate copy.

As for payment, because unlisted procedure codes do not have assigned fees or global periods, payers will generally determine payment for unlisted-procedure claims based on the documentation you provide.

You can suggest a fee by comparing the unlisted procedure to a similar, listed procedure that has an established reimbursement value. This will help put your service in perspective with something familiar to the payer.

Tell the payer how the procedure you’re coding for compares to, and differs from, the assigned procedure code.