Practice Management Alert

Question: Can I append a modifier to an unlisted CPT® code? I’m having trouble getting paid when I use unlisted codes and am wondering whether a modifier might help?

Illinois Subscriber

Answer: Unlisted codes don’t require modifiers because they cannot be matched to any fixed, described procedure, says Rhonda Buckholtz, CPC, CPMA, CRC, CDEO, CMPE, CHC, COPC, CGSC, CPEDC.

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 different or extraneous from the specific procedure code.

When using an unlisted procedure code, it is essential to 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 surrounding the case.

Sometimes, coders can successfully achieve reimbursement by creating a sort of crosswalk between the unlisted code and a code that describes a similar service. You may need to query your provider for the details necessary to illustrate your usage of the code and the services performed.

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 to thoroughly document the procedure and maintain open communication with payers to ensure appropriate reimbursement.