Pain Management Coding Alert

Insurer might have specific rules on documenting unlisted claims.

There’s a very good reason that coders consider unlisted codes a last resort. These nonspecific codes are difficult to get paid; however, they might be your only option in some circumstances.

Help’s here: Experts recommend are a couple of steps that can increase the likelihood that your unlisted procedure claim will achieve your reimbursement goals.

Check out these steps on submitting successful unlisted procedure code claims.

Look to these Unlisted Codes Most Often

While you could theoretically use any type of unlisted procedure code on a claim, you’ll probably most likely use one of the following codes for your practice’s unlisted procedures:

• 20999, Unlisted procedure, musculoskeletal system, general
• 22899, Unlisted procedure, spine
• 64999, Unlisted procedure, nervous system

Best bet: If you think you might have to use an unlisted code, be sure to check your payer’s policy first. They might have some rules on the books for specific unlisted procedure codes, and that knowledge can help you get your claim paid.

Once you’ve decided that you must use an unlisted procedure code, you’re ready to move on to the next step toward filing a successful claim.

Include the Proper Documentation

“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’s Department of Otolaryngology. “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.”

Billing out for unlisted codes are 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.

Experts recommend that you 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.”

Give Good Reasons for Unlisted Code Use

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 the physician performed.

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.