Orthopedic Coding Alert

Here are the five most important points to keep in mind when reporting a claim with an unlisted- procedure code:

1. You should never select a CPT code "that merely approximates" the service the physician provides. If no precise procedure or service code exists, you should report the service "using the appropriate unlisted- procedure or service code," CPT Instructions for Use of the CPT Codebook state.

2. When submitting an unlisted-procedure claim, you should file a "paper" (or manual) claim with the complete operative note and a cover letter that explains in simple, straightforward language exactly what the physician did.

3. Include in Box 19 of the CMS-1500 form (or electronic equivalent) a short description of the unlisted service and indicate that documentation is included.

4. Note that some payers require an electronic claim as proof of "timely filing." For these payers, file the claim electronically and then submit paper documentation with a note stating, "This is not a duplicate claim. This documentation supports an electronic claim." Some carriers have a fax line set up for providers to fax in the additional information supporting the unlisted-procedure code. Any documentation faxed in could be noted also in box 19, "Supporting documentation faxed to carrier."

5. There are no "standard" fees (or global periods) for unlisted-procedure codes. Insurers generally determine payment for unlisted-procedure claims based on the documentation you provide.