Otolaryngology Coding Alert

Rely on this expert advice to help take the stress out of billing unlisted.

Last month, you learned about two scenarios of when reporting an unlisted procedural code was the best (and only) course of action. Unlisted codes are seen as a last resort for good reason — they are often difficult to get paid. Additionally, physicians are skeptical about relying on a seemingly ambiguous code to document hours of hard work.

Good news: Two simple tips can significantly boost your chances at reimbursement when you’ve got to rely on an unlisted code to document a complex procedure.

1. Submit Proper Documentation

“Depending on the insurance company, you might have the option to submit the claim on paper, rather than electronically,” says Kimberly Quinlan. “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.” Ultimately, however, the insurance company will need to process a paper claim submission for the unlisted procedure. You can also indicate the unlisted procedure description in Box 19 of the claim.

Billing out for unlisted codes is notoriously frustrating for this reason. When you don’t back up your claim with documentation, you allow the insurance companies to either deny the claim or reimburse you at a level that does not document the extent of the work performed.

Tip: Submit claims electronically first, even when sending them via paper along with the operative note and progress notes. Why? Only the electronic claim receipt will prove timely filing. Indicate the following on the paper claim submittal: “Documentation Copy, Already Submitted Electronically, Not a Duplicate Claim.”

2. Submit Justification

Submitting documentation of the procedure alone is not enough. You must also explain why the procedure 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, 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 Cobuzzi. “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: Place this information, and any other material for justification, in box 19 of the CMS1500 Claim Form.