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Try These Top-5 Tips for Unlisted-Procedure Claims

Published on Wed Jun 06, 2007

Submit electronic and paper? Avoid duplicate claim denials--here's how

When reporting a claim with an unlisted-procedure code, your supporting documentation can make all the difference in your reimbursement rate. Make the most of your claims with these smart moves:

1. You should never select a CPT code "that merely approximates" the service the physician provides. If no precise procedure or service code exists, you should report the service "using the appropriate unlisted procedure or service code," CPT Instructions for Use of the CPT Codebook state.

2. When submitting an unlisted-procedure claim, you should file a "paper" (or manual) claim with the complete operative note and a cover letter that explains in simple, straightforward language exactly what the physician did. Why: If the person making the payment decision doesn't understand what the physician did, your reimbursement probably won't properly reflect the effort involved, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. Either avoid or explain medical jargon and difficult terminology. And, if appropriate, you may include diagrams or photographs to better help the insurer understand the procedure.

3. Include in box 19 of the CMS-1500 form (or electronic equivalent) a short description of the unlisted service and indicate that you included supporting documentation.

4. Note that some payers require an electronic claim as proof of "timely filing." For these payers, file the claim electronically and then submit paper documentation with a note stating, "This is not a duplicate claim. This documentation supports an electronic claim."

Some carriers have a fax line set up for providers to fax in the additional information supporting the unlisted- procedure code. You should also note in box 19 that you faxed documentation in: "Supporting documentation faxed to carrier."

5. There are no "standard" fees (or global periods) for unlisted-procedure codes. Insurers generally determine payment for unlisted-procedure claims based on the documentation you provide.

You can suggest a fee by comparing the unlisted procedure to a comparable code in the cover letter and noting how the two procedures are different to support your suggested fee.

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