Radiology Coding Alert

Answer these questions for your best chance of adequate reimbursement.

Burn this CPT instruction into your brain: "Do not select a CPT code that merely approximates the service provided." This rule is key for compliant coding, but it leaves you with the tough job of submitting a claim without a procedure-specific code. Here are some do's and don'ts to help boost your chances of getting the payment your practice earned.

Do Explain the Procedure in Layman's Terms

If CPT doesn't offer a code specific to the service provided, then you should report the appropriate unlisted-procedure code, such as 37799 (Unlisted procedure, vascular surgery) for vascular sclerotherapy.

Any time you file a claim using an unlisted-procedure code you should include a cover letter stating why you are using the unlisted code, says Rebecca Lopez, CPC, coding specialist for Bright Health Physicians' compliance department in Whittier, Calif. This separate report should explain in simple, straightforward language exactly what the physician did.

According to CPT Assistant (April 2001), you need to submit supporting documentation identifying the specifics of the procedure, such as the procedure report, when you file the claim. The supplemental documentation should define the service (nature, extent, need) and the time, effort, and equipment required. CPT Assistant explains you also may include the following factors:

• Whether the physician required assistance to perform the service
• Whether the procedure was independent of other services
• Whether the physician performed additional procedures at the same site
• Number of times the physician performed the service at the encounter
• Extenuating circumstances that complicated the service.

You may even want to include diagrams or photographs to help the person reviewing your claim better understand the procedure.

Why: Your payers will consider claims with unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don't always dictate the most informative notes.

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, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Don't Try to Use Modifiers or Multiple Units

You should not append modifiers to unlisted-procedure codes or try to report them more than once per encounter.

Reason: The point of modifiers is "to indicate that a service or procedure performed was altered by some specific circumstance, but not changed in its definition or code. Since unlisted codes do not include descriptor language that specifies the components of a particular service, there is no need to 'alter' the meaning of the code," CPT Assistant states. If the radiologist performs the  procedure more than once at the same encounter, report the unlisted code only once.

The "unlisted code does not identify a specific unit value or service," CPT Assistant explains.

Do Suggest an Appropriate Fee for the Service

Unlisted procedure codes do not appear in the Medicare Physician Fee Schedule, so they do not have assigned fees or global periods. Your payers will generally determine payment for unlistedprocedure claims based on the documentation you provide.

You can suggest a fee by comparing the unlisted procedure to a similar, listed procedure with an established reimbursement value. It helps put your service in perspective with something reviewers are familiar with, experts say.

Best bet: Rather than leave it up to the insurer to determine which code is the closest to what your physician performed, you should explicitly make reference to the nearest equivalent listed procedure, Lopez recommends. After all, the treating physician is best equipped to make this determination.

Tell the carrier how the procedure you're coding for compares to, and differs from, the assigned procedure code, Cobuzzi advises. Answer these questions, she advises: Was the unlisted procedure more or less difficult than the comparison procedure?

Did it take longer to complete and, if so, by how much? (Try to provide percentages whenever possible.)

• Was there a greater risk of complication?
• Will the patient require a longer recovery and more postoperative attention?
• Did it require special training, skill, or equipment?
• Any of these factors can make a difference in the reimbursement level you may expect.

Don't Let Denials Go Unappealed

Even the best documentation won't always get you the reimbursement your radiologist deserves for an unlisted procedure. If payment is not appropriate, you may need to appeal, Cobuzzi says.

Find out where your unlisted claim is going. "Make sure you get the name and department, so you can follow up your request," Lopez says.

Good practice: When your radiologist repeatedly performs the same type of unlisted procedure, prepare an information file so you don't have to reinvent the wheel every time you submit a claim. Each time a carrier denies a similar claim, you will already have an appeals packet ready to send the payer to defend your claim.