Orthopedic Coding Alert

Question: It seems whenever our practice reports a service using an unlisted procedure CPT® code, we run into issues. Is there any way to alleviate the potential for trouble when reporting unlisted procedure codes?

Tennessee Subscriber

Answer: When your provider performs a procedure that you need to code with an unlisted procedure code, getting paid is often more involved than with listed procedure codes. There are some ways that you can best prepare your unlisted procedure claims to give them the best possible chance of payer acceptance.

Spot-on documentation a must: “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. “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.”

Reporting unlisted codes is 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. 

It is recommended to 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.”

Make sure it’s justified: 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 performed by the physician. 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, it’s important to understand the necessary measures required to maximize your chance at proper reimbursement.