Radiology Coding Alert

It's your practice's job to recommend an appropriate fee

If you perform a procedure for which CPT Codes doesn't include a code, chances are your only option is to report an unlisted-procedure code, submit a written report to the carrier, and hope for the best. To ensure that your payer properly rewards your unlisted-service claims, our experts offer three tips.

Step 1: Describe the Procedure in Plain English

When you report an unlisted-procedure code (for example, CPT 76499, Unlisted diagnostic radiographic procedure), you should submit a full operative report to describe the procedure or service - but when it comes to fair reimbursement, the operative notes alone won't be enough. You should include a separate report that explains in simple, straightforward language exactly what the radiologist performed.

"There's no 'standard' fee for an unlisted-procedure code," says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. "Insurers consider claims on a case-by-case basis and determine payment based on the documentation you provide. Unfortunately, claims reviewers, especially at lower levels, do not have a uniformly high level of medical knowledge, and physicians don't always dictate the most accessible notes."

Submit Great Documentation, Collect Great Pay

The radiology coder should act as an intermediary between the radiologist and the claims reviewer, providing a description of the procedure in layman's terms.

"If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Brick, N.J. Be careful to 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.

For example, CPT Include no specific code to describe an x-ray of the entire leg using a single film, so you should report 76499 for this service. To describe the procedure, you should use the radiologist's notes as a guide, stressing the main points of the procedure and why it was necessary.

A sample narrative might read, "The orthopedic surgeon ordered a complete leg x-ray on the same film to detect possible bone abnormalities. We performed a full-leg x-ray in both the standing and supine positions."

"A little extra effort to write a clear description of the procedure can go a long way toward improving your reimbursement," Cobuzzi says.

Step 2: Compare the Procedure You Performed to a Procedure That Has an Existing Code

One way insurers determine payment for unlisted procedures is by reading your procedure description and comparing it to a similar, listed procedure with an established reimbursement value, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

If a radiologist performs radiologic supervision and interpretation (RS&I) during kyphoplasty (22899, Unlisted procedure, spine), for example, he should report 76499. Because surgeons often compare kyphoplasty reimbursement to their vertebroplasty fees (22520, Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic), many radiology practices base kyphoplasty RS&I reimbursement on their fees for vertebroplasty RS&I (76012, Radiological supervision and interpretation, percutaneous vertebroplasty, per vertebral body; under fluoroscopic guidance).

'Next-Closest' Code Isn't Good Enough

Instead of letting the insurer determine the "next-closest" code, you should explicitly reference the nearest equivalent listed procedure in your explanatory note. You should also specifically note how the unlisted procedure differs from the next-closest listed procedure, Sandham says.

For example, was the claimed unlisted procedure more or less difficult than the "comparison" procedure? Did it take longer to complete? 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 level of reimbursement you may expect.

Often, however, no "comparison" code exists. You can still devise an appropriate fee if you do a little research.

"What we generally do when we work with a client on unlisted services is to begin with their costs (equipment, supplies, training, etc.), determine the number of these services to be performed on an annual basis, distribute the costs across the population, and establish the value of the unlisted procedure," says Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc. in Dallas, Ga. "Then we locate a procedure that is reimbursed at or near this amount and make the pitch to the payer."

Step 3: Enlist Outside Help

Medical technologies often evolve faster than the CPT manual, and drug and equipment manufacturers have a vested interest in making sure that carriers pay physicians for using the latest innovations, even if CPT codes don't exist to describe them.

If your radiology department uses equipment and techniques for which CPT does not include a code, you may be able to enlist the manufacturer's help collecting appropriate reimbursement.

Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies, Jandroep says. And they are sometimes instrumental in gaining approval for new CPT codes to describe previously unlisted procedures.

But use caution when applying manufacturers' suggestions. Remember: You are responsible for the accuracy of your claims, and you should never misrepresent a claim to gain payment. Stick to unlisted-procedure codes when no other code describes the procedure you performed, and always provide ample documentation to justify the claim's necessity.