Pediatric Coding Alert

Question: Can I append a modifier to an unlisted CPT^® code? I’m having trouble getting paid when I use unlisted codes. Might a modifier help?

Idaho Subscriber

Answer: A modifier won’t likely help you get paid. This is because unlisted codes cannot be matched to a specific procedure and therefore there’s nothing specific to modify.

For example, if you’re using an unlisted procedure code, you cannot append, say, modifier 22 (Increased procedural services), because doing so suggests that you know you did something of unusual complexity beyond the specific procedure code.

When using an unlisted procedure code, it is essential that you provide clear and detailed documentation describing the procedure or service performed. This may include a comprehensive summary of the intervention, the rationale for its use, the equipment or materials involved, and any complications or specific circumstances including procedural time surrounding the case.

However, sometimes, coders can successfully achieve reimbursement of an unlisted procedure by creating a sort of crosswalk comparing it to a similar service. You may need to query your provider for the details necessary to illustrate your usage of the chosen code and the services performed.

Keep in mind: It is crucial to use unlisted procedure codes only when no existing code accurately reflects the specific service or treatment provided. The use of unlisted codes may require additional approval from insurance companies or other payers, and there could be challenges in obtaining reimbursement for these services. Therefore, it is important that you thoroughly document the procedure and maintain open communication with payers to ensure appropriate reimbursement.