Unlisted procedure coding? Here's how you should tread

Published: 24th May 2011
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Always remember this: You should never select a CPT code that merely approximates the service provided. Even though this rule is important for compliant coding, it leaves you with the tough job of submitting a claim minus a procedure-specific code. Here's what you should do and not do to improve your chances of getting the payment your practice earned.


Make it a point to explain the procedure in layman's terms. If CPT does not offer a code specific to the service provided, then you should report the proper unlisted-procedure code, such as 37799 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. This separate report should explain in simple straightforward language exactly what the physician did.


As per CPT Assistant (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 and the time, effort, and equipment required. As per CPT Assistant, you may also include some other factors.


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


You should not try to use modifiers or multiple units. You should not add modifiers to unlisted procedure codes or try to report them more than once every encounter.


What's more, you should also suggest a proper fee for the service. Unlisted procedure codes don't appear in the Medicare Physician Fee Schedule; as such they don't have assigned fees or global periods. Normally, your payers will determine payment for unlisted procedure 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. According to experts, it helps put your service in perspective with something reviewers are familiar with.


You shouldn't let denials go unappealed. Even the best documentation won't always get you the reimbursement your radiology deserves for an unlisted procedure. If payment is not proper, you may need to appeal. Figure out where your unlisted claim is going. See to it that you get the name and department so that you can follow up your request.


For more on this and for other specialty-specific articles to assist your radiology coding, sign up for a good coding resource like Coding Institute.


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