Otolaryngology Coding Alert

Payment for unlisted-procedure codes requires preparation and documentation

If you-ve ever filed a claim using an -unlisted- procedure- code, you know how much effort is involved. To ensure that payers properly reward your physician's effort (and your work in preparing the claim), our experts offer you three tips to improve your claim's effectiveness.

1. Don't Approximate

The only time you should call on an unlisted- procedure code (for example, 31899, Unlisted procedure, trachea, bronchi; or 92700, Unlisted otorhinolaryn-gological service or procedure) is when no CPT code properly describes the procedure your ENT performs.

By the same token, however, you shouldn't select a code that is -close enough- in lieu of an unlisted- procedure code, says Heather Corcoran, coding manager at CGH Billing Services, a medical billing firm in Louisville, Ky.

For instance: You may select an unlisted-procedure code if the physician performs the procedure using a device other than what an existing CPT code describes or if the physician directs the procedure toward a specific anatomical location, but the intent of the procedure is somewhat different from an existing code.

Crucial point: 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 guidelines state.

Roll up your sleeves: Reporting an unlisted-procedure code will require a special report or documentation to describe the service. But correct coding demands that you use a code that most accurately represents the service the physician provides, and not a code that is similar but actually represents a different service.

2. Describe the Procedure in Plain English

Anytime you file a claim using an unlisted-procedure code, you must submit a full operative report to describe the procedure or service.

Crucial point: 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 ENT did.

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.-
 
Here's why: Insurers consider claims for unlisted-procedure codes on a case-by-case basis, says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.

-Unfortunately, claims reviewers, especially at lower levels, don't always have a high level of medical knowledge, and physicians don't always dictate the most accessible notes,- Sandhusen says. Part of the coder's job in preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman's terms.

-If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved,- says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Keep it simple: Avoid or explain medical jargon and difficult terminology. If appropriate, include diagrams or photographs to help describe the procedure you are billing. -You should try to keep the description short and simple,- Hammer says.

Real-world example #1: A young child requires a post-fistula trach tube change. The child is restless and unruly and will not submit to the procedure in the physician's office. Therefore, the ENT elects to perform the procedure in the operating room with the patient under anesthesia. In this case, your best code choice is 31899 (Unlisted procedure, trachea, bronchi).

Your documentation should state, -The physician chose to perform the procedure under anesthesia in the OR rather than in the office because the patient was a young child who could not be otherwise restrained. This was the best method to ensure a positive outcome and prevent any undue harm to the patient. CPT does not contain a code to describe a procedure of this type, and therefore we are submitting an unlisted-procedure code.-

3. Compare the Procedure to an Existing Code

If you want to gain appropriate payment for an unlisted-procedure claim, you should provide the insurer with an appropriate place to begin.

Often, insurers pay for an unlisted-procedure claim by reading your procedure description and comparing it to a similar, listed procedure with an established reimbursement value, Corcoran says.

Crucial point: There are no -standard- fees for unlisted-procedure codes. Insurers generally determine payment for unlisted-procedure claims based on the documentation you provide.

Take charge of your claim: Rather than allow the insurer to determine which is the -next closest- code on which it should base your payment, you should explicitly reference the nearest equivalent listed procedure in your explanatory note.

-If you let the insurer choose the -comparison- code for you, you could end up having to fight it later. For instance, the payer might compare your claim to something valued much lower than the unlisted procedure that you performed,- Corcoran says.

Provide specific details: You should also note how the unlisted procedure differs from the next-closest listed procedure, Sandhusen says.

For example, was the claimed unlisted procedure more or less difficult than the comparison procedure? Did it take longer to complete and, if so, by how much (try to provide percentages, whenever possible)? Was there a greater risk of complication? Will the patient require a longer recovery and more postoperative attention? Did it require special training, skill or equipment? Any of these factors can make a difference in the level of reimbursement you may expect.

Real-world example #2: CPT doesn't contain a code for noninvasive endoscopic staple diverticulectomy, also called endoscopic staple-assisted Zenker's diverticulectomy (ZD). Therefore, you should report this service using unlisted-procedure code 43499 (Unlisted procedure, esophagus).

In your documentation, mention that otolaryngologists traditionally used a transcervical approach (43130, Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach), which requires a lateral neck incision, to remove a ZD (a back-of-the-throat pouch). However, most now prefer the endoscopic stapling procedure, which requires no incisions and resects the common wall with a gastrointestinal stapler. In this way, the unlisted procedure you are reporting is similar to but less invasive than 43130, with less risk of complication.