Ensuring Compliance and Payment for Unlisted Codes

Securing payment for CPT^® unlisted codes can be challenging in the medical billing world. These codes, which represent services or procedures without a designated listing, often create obstacles for reimbursement. However, with the right approach and a clear understanding of the new CPT^® 2024 guidelines, these challenges can become opportunities. In this eBrief, we’ll provide actionable insights — from helping providers craft precise documentation to navigating payer-specific requirements — to ensure unlisted codes lead to approved claims. Let’s unlock the secrets to getting paid for the unlisted!

Defining Unlisted Codes

The medical field is constantly evolving with new technology, techniques, and treatments emerging daily. While this progress is exciting, the coding world often takes time to catch up, particularly in the CPT^® realm. Although CPT^® code books are updated annually, introducing a new Category I code for a procedure can take years. Typically, new procedures are first assigned a temporary Category III code, allowing the CPT^® Editorial Panel to gather data on emerging technologies, services, and procedures. If a Category III code is widely used, the procedure may eventually receive a permanent Category I code.

Included within Category I are unlisted service and procedure codes, which typically end with a ‘9’ and include the word “unlisted” in their descriptor. A full list of these codes can be found in the guidelines for each section of the CPT^® code book. While unlisted codes are intended as a last resort, they play an important role in ensuring accurate reporting when no specific code exists.

When to Use an Unlisted Code

Healthcare providers must always use the most accurate and specific code that best describes the procedure performed. Proper CPT^® code selection is critical for accurate billing and compliant payment. Failure to do so can result in violations and penalties. When reviewing an operative report, you may notice discrepancies between the code descriptions and the provider’s procedural notes. In some cases, no existing code fully captures what was performed — this is where unlisted codes become necessary.

Note: If you know in advance that a procedure lacks a dedicated code, contact the payer to obtain prior authorization. This step can reduce the likelihood of payment denials for elective procedures. Most payers offer a prior authorization form, allowing the surgeon to detail the planned procedure and its medical necessity.

Before you commit fully to using an unlisted code, make sure there aren’t any Category III codes or modifiers that would better inform the payer of the work performed. For example, if the provider started a procedure, but had to stop due to extenuating circumstances or other reasons, you might append the appropriate code with modifier 52 or 53, instead of downgrading the service to an unlisted code. And if there is a Category III code that describes the procedure better than an unlisted code, you must use the Category III code.

How to Price an Unlisted Procedure

Once you’ve determined there is no other way to bill the procedure, locate the correct unlisted code in the appropriate section and subsection of the CPT^® code book. Select the unlisted code, then identify a comparable code that is not an unlisted code. Use the fee for this comparable code as a baseline for determining the charge. For instance, if the comparable code charge is $2,000 and the provider's documented work is 50% greater, you could adjust the fee to $3,000. This underscores why it is important to educate your providers on the proper documentation to support the use of unlisted codes.

You should not use modifiers that describe alteration of the service or procedure on unlisted codes. Modifiers state that you are modifying the procedure in some way; and unlisted codes don’t have definitions that can be modified. As of Jan. 1, 2024, however, you may append modifiers to unlisted codes to denote laterality or finger/toe modifiers, distinction (e.g., modifier 51 or 59), place of service, and co-surgeon or assistant surgeon, if indicated.

Also new for 2024, unlisted codes can be reported alongside other CPT^® Category I and III codes, including additional unlisted codes. This may be necessary to fully describe a service that cannot be adequately captured by a single code.

Heed Payer Policy When Submitting Claims

Now you’ve got to submit the claim. This is where billers who are familiar with different payer policies can be particularly valuable. Every payer handles unlisted codes differently, but they typically require the comparable CPT^® code or a description of the procedure submitted on the claim. For Medicare Part B, this concise statement must be 80 characters or less on Item 19 of the CMS-1500 paper form or the equivalent electronic media claim (EMC) form. They most likely will want the procedure note, either submitted directly with the claim or they may ask for it later.

Other items to consider submitting include:

• The history and physical (H&P) or other note showing the decision to do the surgery was made with the patient, and the medical necessity of such

• A cover letter with a brief summary of why an unlisted code was used

• A discharge summary

• Any diagnostic reports

If you are submitting the claim to your local Medicare Administrative Contractor (MAC), consult their website for specific instructions. For example, Noridian Healthcare Solutions provides detailed guidance on their Medicare Part A website regarding the submission process for unlisted procedure codes:

An unlisted procedure code must have a concise description of the service or procedure rendered in Form locator 80 on the CMS-1450 claim form or electronic equivalent in the service line description. In the concise description of the procedure, it is helpful to include how the procedure was performed (e.g., laparoscopic, trans-nasal, infusion, with clip, type of graft, etc.), the body area treated and why it was performed.

Example: 85999 - Urine for Eosinophils

The electronic equivalent for form locator 80, 2300/2400 NTE, holds up to 80 characters for the concise statement. If the description does not fit in 2300/2400 NTE, providers who submit paper claims should include an attachment to describe the service or procedure. Also, an attachment can be submitted for EMC claims using the PWK submission method. See PWK article titled ‘Submitting Paperwork (PWK) Electronically.’

Please do not submit a written request or contact the Noridian Provider Call Center to inquire if the description is appropriate for payment. We cannot determine if the comment is sufficient for payment without viewing the entire claim.

In addition to the provider requirement of a clear concise description of the service or procedure of unlisted codes, Noridian may ask for medical records to validate an unlisted procedure. Providers should not submit medical records unless an Additional Documentation Request (ADR) is issued.

Watch for Claim Remittance

Once the claim is submitted, monitor for requests for additional documentation and respond to ADRs promptly. Keep an eye on payments or denials, ensuring the claim is not underpaid. For example, in the case of a $3,000 claim, a $300 payment would be clearly insufficient. You should appeal both underpayments and denials. A clear demand letter for payment, either written by your provider or collaboratively crafted, can strengthen your case.

Since securing proper payment for unlisted codes can be a time-intensive process, ensure they are used only when absolutely necessary. Maintaining open communication with your providers is critical to supporting accurate documentation and achieving successful reimbursement outcomes.

How AAPC Can Help

Navigating unlisted CPT^® codes can be challenging, but with over 35 years of experience, AAPC provides resources and strategies to help healthcare organizations overcome billing challenges, improve documentation, and secure accurate reimbursement. Here’s how AAPC can support your success related to unlisted codes:

• Audit Services: Leverage expert audits to identify gaps, improve compliance, and enhance the accuracy of claims involving unlisted codes.

• Coding Tools and Resources: Access tools like Codify by AAPC to streamline workflows, verify comparable codes, and navigate payer policies with confidence.

• Corporate Team Training: Equip your team with training that enhances their understanding of coding nuances, including unlisted CPT^® codes, and improves their ability to craft precise documentation.

• Educational Resources: Tap into webinars, workshops and articles to keep your team updated on the latest guidelines for unlisted codes and best practices for handling claims efficiently.

Conclusion

Securing proper reimbursement for unlisted CPT^® codes requires a proactive, informed approach to coding, documentation, and payer communication. By understanding the latest guidelines and implementing best practices, healthcare organizations can transform challenges into opportunities for accurate and compliant billing. With AAPC’s expert guidance, tools, and resources, you can minimize denials, reduce administrative burdens, and achieve fair payment for all services provided.

Resources

• Unlisted Procedures: Strategies for Successful Reimbursement (facs.org)

• Unlisted Code Billing - JF Part A - Noridian (noridianmedicare.com)

• CPT^® Presents Updated Unlisted Procedure Guidelines : News You Can Use (aapc.com)

• Unlisted Procedure Codes: 3 Tips - AAPC Knowledge Center (aapc.com)

• How to Bill and Get Paid for Unlisted Procedures (aaos.org)