Otolaryngology Coding Alert

The more information you can include on your claim, the better. 

No coder likes to file a claim with an “unlisted” procedure code, but sometimes that’s your only choice. Last month’s issue of Otolaryngology Coding Alert shared four ways to help ensure your “unlisted” claims pass muster. Now our experts offer three more tips to boost your chances of adequate payment. 

1. Don’t Skimp on the Information 

If your provider uses equipment and/or techniques for which there is no dedicated CPT® code, you may be able to enlist the manufacturer’s aid to receive appropriate reimbursement. The more information you can include, the better. But also keep in mind that equipment manufacturers are not necessarily vested in compliant coding and you sometimes have to take their advice with a grain of salt. 

Here’s why: Manufacturers often maintain free information, resources and help lines to advise physicians on how to approach insurers regarding new technologies. 

“Use caution when applying manufacturer suggestions, however, because you are responsible for the accuracy of your claims,” warns Gregory Przybylski, MD, with the New Jersey Neuroscience Institute, JFK Medical Center, in Edison.  “You should never misrepresent a claim to gain a payment. Ultimately, the AMA in cooperation with the professional medical associations determines the rules for appropriate use of CPT®.” 

Insurer clearance: Some private or third-party payers might not want to handle claims with unlisted codes. If you aren’t sure whether the payer will accept a claim, talk with your representative and get any clearance in writing. Include a copy of their approval when you submit the claim. 

“If pre-authorization is necessary, it’s best to establish coverage for the specific unlisted code at that point,” suggests Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Co. “It’s also helpful to have the comparative code available for reference at pre-authorization.” 

Bonus: Medical specialty societies might also be able to offer guidance or supporting information about the procedure your physician performed. 

2. Include a Reasonable Comparison Procedure

Insurers consider unlisted procedure claims on a case-by-case basis. Any payment you receive will be based on comparing your procedure description to a similar, valid CPT® procedure code with an established reimbursement value. This comparison code should be similar in physician work, malpractice risk, and practice expense when compared to the unlisted procedure. 

Tip 1: You should consider comparison codes that use a similar approach as well as represent a similar service when such a comparison code is available.

Referring to an existing code on your claim can help your insurer determine an adequate payment. If possible, look for a CPT® code for the nearest similar procedure. Also, describe how the procedure that your surgeon does differs from the next-closest listed procedure.

Tip 2: Don’t let the insurer determine which CPT® code is the “next closest” for your physician’s service. 

3. File Twice for Better Attention

“We send the claim in electronically with the description of the unlisted procedure (e.g., ‘middle ear endoscopy’) in box 19 for 69799 because we only get proof of timely filing with electronic filing even though we know the claim will not get adequately processed with electronic submission,” 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.  “Then I submit the claim on paper with the cover letter, op note, and all the other supporting documentation.  I have a stamp that I stamp on the CMS1500 form that says: ‘Documentation Claim – Already sent electronically – Not a duplicate claim submission.’”