Do you have trouble deciding if and or when to use an unlisted codes vs/using a CPT code that "is close to" what you want. I've tried to give some insight into what I think is appropriate usage of the unlisted CPT codes and how to report with the insurance payers...
When a provider performs a procedure, or provides a service, that a coder cannot find a specific CPT® code to accurately reflect that specific procedure or service, a coder may report unlisted codes, which are included throughout each section and subsection of the CPT Manual and usually end in “99”. (e.g., code 59899 in the maternity care and delivery section).
Physicians sometimes perform procedures that fall into this category due to a patient’s altered anatomy, a trauma, burn(s), or some other medical reason are not accurately captured in standard listed CPT codes.
Coders should only report unlisted codes for a test or procedure as a last resort. This does not mean you should never use them. But make sure you’ve done your “due diligence” to investigate and determine that there is no other code that more appropriately reflects the procedure or service.
This is especially important for surgical coders and billers to understand, as CMS does not assign any Relative Value Units (RVU's) to unlisted codes. Many of the unlisted CPT codes are grouped to ambulatory payment classifications with little or no reimbursement.
It may be tempting to report a code that is a close description of what the physician documented. However, just because you identify a code that closely matches the procedure or service does not mean it is the correct choice.
Note that when reporting unlisted codes, check to make sure that you don’t overlook reporting an appropriate category III code. You may discover that there is a Category III code for emerging technology that you can include with your unlisted code.
Be sure to carefully read what is actually in your physician documentation or operative report. Don’t just assign codes from the operative report headings; review the entire operative record. You may discover that the physician truly performed a procedure for which there is a listed CPT code, and you simply need to append a modifier (e.g., modifier -52 for a reduced service, modifier -53 for a discontinued service).
If there are additional procedures performed in the same operative session, for which specified CPT codes are appropriate, also include those codes on your claim
The CPT Manual also includes unlisted codes for evaluation and management (E/M) services. Providers may use these unlisted E/M codes for services such as an intra-operative consultation between surgeons and physicians in the operative suite or giving medical clearance for athletic competitions or travel to foreign countries.
The next issue that you will be confronted with, is determining the appropriate amount to charge for the unlisted service. Discuss with your physician the complexity of the service, the amount of time the provider spent rendering the service, and the equipment or supplies used. I have also looked at the RVU amount on those procedures that are 'close' but not an exact match, in arriving at what is a 'fair' RVU or chargeable amount for the unlisted procedure. Put all these factors together to arrive at a dollar amount to bill to the insurance carriers.
When submitting claims that include unlisted codes it is very common for insurance carriers or third-party payers to respond with a denial of payment. CMS and most private payers will edit out the claim from further processing until you send them additional supporting documentation (e.g., the operative note, clinical study references from specialty organizations, a letter detailing medical necessity to support the claim).
Once you receive the electronic denial from the payer requesting supporting documentation, respond back to them by sending a cover letter with your documentation describing the unlisted procedure completely and concisely. Include a copy of the CMS 1500 or UB claim form with the unlisted CPT code, and diagnosis code(s), a copy of the operative or procedure record and path report if appropriate.
Ask the carrier to adjudicate your claim within a standard time frame (e.g., four weeks). If you do not hear from the payer within that requested time, follow-up again with the payer and inquire if they received your claim, If so, ask when they will have the claim processed and payment submitted to you. If not, ask if you can expedite the claim and forward via fax or secure e-mail.
In closing, just realize that CPT has included these 'unlisted' codes for coders to use. Don't avoid using them, or use them when you look at an operative report and think it's 'too hard' to code... just use unlisted codes wisely! You'll be surprised at how successful reimbursement can be when you put all the factors together.