Otolaryngology Coding Alert

Think ‘streamlined’ and ‘simple language’ to find success.

If you have no option but to submit an unlisted code such as 42699 (Unlisted procedure, salivary glands or ducts), 69399 (Unlisted procedure, external ear), or 31299 (Unlisted procedure, accessory sinuses), there’s still hope for adequate reimbursement. Start your claim with the following tips in mind.

Tip 1: Keep Documentation Simple and Clear

The only time you should call on an unlisted procedure code (for example, 31299, Unlisted procedure, accessory sinuses) is when no CPT® code properly describes the procedure your physician performs.

By the same token, however, you shouldn’t select a code that is “close enough” in place of an unlisted-procedure code.

Example 1: If the ENT cauterizes an olfactory nerve endoscopically via the ethmoid sinus, you should report 31299 because you won’t find an endoscopic code to report this.

Keep it simple: Avoid or explain medical jargon and difficult terminology when describing your surgeon’s service. If appropriate, include diagrams or photographs to help describe the procedure you are billing.

Example 2: Your otolaryngologist performs Thornwaldt/Tornwaldt cyst removal. You should report the unlisted procedure code 42999 (Unlisted procedure, pharynx, adenoids or tonsils). Your documentation should fully describe the procedure, including a letter from the surgeon explaining the need for the nasopharynx excision, and you should also submit a copy of the operative report with the claim.

Include a separate cover letter with your claim that fully explains the work involved. Some groups ask physicians to highlight via circling sections of the op note, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

“Do not use highlighters as that just blacks out the content when the op note when it is scanned by the payer,” she advises. Providers can also make notes on the actual documentation of services to indicate any description of the procedure performed. Any notes regarding the time, effort, and equipment necessary to provide the service will boost your chances of getting the claim paid.

Tip 2: Let the Payer Know Why You Chose ‘Unlisted’ 

Another important detail to include in the cover letter is an explanation of why you’re reporting an unlisted code. 

Example: The note explaining why you chose an unlisted code might read, “The Instructions for Use of CPT® Codebook state, ‘Do not select a CPT® code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.’ No CPT® code currently exists for an endoscopic procedure on the middle ear. Therefore, I am compliantly submitting 69799 (Unlisted procedure, middle ear) for my services provided to your insured when I performed endoscopic resection of a Eustachian tube lesion.” 

Tip 3: Report a Single Unit

Because the unlisted codes don’t have valuations, you should always bill with a maximum of one unit of service. 

“While many procedures may involve a series of codes, known as component coding, the unlisted code is meant to encompass all of the additional procedures for which there is no CPT® code available to report,” explains Gregory Przybylski, MD, with JFK Medical Center, in Edison, N.J.  

Support: According to the April 2001 CPT® Assistant, “… When performing two or more procedures that require the use of the same unlisted code, the unlisted code used should only be reported once to identify the services provided. This is due to the fact that the unlisted code does not identify a specific unit value or service. Unit values are not assigned to unlisted codes since the codes do not identify usual procedural components or the effort/skill required for the service…” 

Tip 4: Forego the Modifiers 

Modifiers are used to indicate that the service your provider performed was altered a bit from the specific CPT® code descriptor, but not changed from the basic service. They can also be used to provide payers with additional details about the service – but that doesn’t work with “unlisted” claims since we are giving the full code description to the payer for this application of the unlisted code.  It therefore would have no reasons to be modified, Cobuzzi says.

“While proper use of modifiers for existing CPT® codes is critical in many circumstances to receive proper payment, they are not intended to be applied to unlisted codes,” says Przybylski. 

Avoid: Do not append modifiers to unlisted procedure codes, however, because the unlisted codes do not describe specific procedures. 

Coming next month: Two final tips to help substantiate your unlisted claims and streamline your payment.