Coding examples
| Procedure performed | Unlisted CPT code reported on claim form | Comparison CPT code referenced in cover ... |
| Laparoscopic subtotal gastrectomy with R ... | 43659, Unlisted laparoscopy procedure, s ... | 43633, Gastrectomy, partial, distal; wit ... |
| Laparoscopic gastrojejunostomy | 43659, Unlisted laparoscopy procedure, s ... | 43820, Gastrojejunostomy; without vagoto ... |
| Laparoscopic internal hernia repair | 44238, Unlisted laparoscopy procedure, i ... | 44050, Reduction volvulus, intussuscepti ... |
| Laparoscopic pylorotomy | 43659, Unlisted laparoscopy procedure, s ... | 43800, Pyloroplasty |
What are unlisted procedure codes in the surgery section?
CPT and HCPCS codes are reviewed and paid. With a few exceptions listed below, these codes will no longer be managed through the prior authorization process. ... 33999 UNLISTED CARDIAC SURGERY 36299 UNLISTED PROCEDURE VASCULAR INJECTION 37501 UNLISTED VASCULAR ENDOSCOPY PROCEDURE 37799 UNLISTED PROCEDURE VASCULAR SURGERY 38129 ;
What is an unlisted Procedure Code?
When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are des- ignated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.
Is CPT CPDE 36415 payable?
When routine venipuncture CPT code 36415 is reported with Evaluation and Management (E/M) office visit codes (99201-99205 and 99211-99215) then the routine venipuncture code is included in the reimbursement for office visit E/M services and not reimbursed separately. Modifiers will not override the edit.
Where are unlisted procedures located in the CPT manual?
specific CPT or Level II alphanumeric HCPCS code. The CPT code book lists a number of unlisted service or procedure codes, which can be found at the end of a section or subsection. Alternatively, a summary list of the unlisted CPT codes can be found in the Guidelines section for each chapter of the CPT code book. The long descriptors for these
What does unlisted procedure code mean?
Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established. According to the Current Procedural Terminology Instructions for use of the CPT Codebook, select the name of the procedure or service that accurately identifies the service performed.
What is an example of an unlisted procedure?
However, unlisted CPT codes, when reported with appropriate documentation, should be reimbursed....Coding examples.Procedure performedUnlisted CPT code reported on claim formComparison CPT code referenced in cover letterLaparoscopic pylorotomy43659, Unlisted laparoscopy procedure, stomach43800, Pyloroplasty6 more rows•Aug 2, 2017
How do you bill unlisted procedures?
When billing a service or procedure, select the CPT or HCPCS code that accurately identifies the service or procedure performed. If no such code exists, report the service or procedure using the appropriate unlisted procedure or Not Otherwise Classified (NOC) code (which often end in 99).
When an unlisted procedure or service code is reported?
When an unlisted procedure or service code is reported, this "report" must accompany the claim to describe the nature, extent, and need for the procedure or service along with the time, effort, and equipment necessary to provide the servie. appear throughout CPT sections to clarify the assignment of codes.
Can modifier 59 be used with an unlisted CPT code?
Is it appropriate to append a modifier to an unlisted CPT code? The answer is no. Modifiers exist solely to amend a specific and established definition of a procedure or service. By their very nature, unlisted CPT codes are undefined; amending them with a modifier will not make them any more specific.
Do unlisted CPT codes have global days?
for all unlisted codes, even if the procedure has been prior authorized. Unless determined otherwise by medical review, all unlisted codes in the range 10000-69999 are assigned a 90-day global period.
Is CPT code 43659 an unlisted code?
Note: Oxford uses unlisted codes to report laparascopic gastric bands (CPT 43659) and laparascopic gastric bypass (CPT 44238)....Gastric Surgery for Obesity.CPT CodeDescription43659Unlisted laparoscopy procedure, stomach44238Unlisted laparoscopy procedure, intestine8 more rows
What accompanies a claim when an unlisted code is used?
Claims using unlisted codes must be accompanied by specific information about the service and/or procedure and supporting documentation. That documentation varies by payer. Billing/claims staff should understand each payers' process for submitting claims with unlisted codes.
How to facilitate claims adjudication for unlisted codes?
To facilitate claims adjudication for unlisted codes, include the operative report (if you can attach records) and provide a suggested fee by comparing the procedure to the type of work required for a similar procedure within an assigned fee schedule. Author.
What is a Category III code?
Category III codes, although not always covered, allow providers to report the procedures so that claims data can be evaluated for frequency. This information is helpful when reviewing the need to replace a Category III code with a Category I code. Unlisted procedure codes are identified as XXX99 or XXXX9 codes and are located at the end ...
Should a physician report a CPT code?
Per Chapter 1 of the National Correct Coding Initiative Policy Manual for Medicare Services, “A physician should not report a CPT® code for a specific procedure if it does not accurately describe the service performed.
Can you report unlisted procedures?
Reporting Unlisted Procedure Codes. You may claim unlisted procedure codes only if an existing CPT® Category I or Category III code does not describe the procedure you wish to report.
What is an unlisted code?
Unlisted or not otherwise classified (NOC) and miscellaneous codes do not provide clear information about the service or item being billed. Paramount requires that additional information accompany claims for any unlisted and miscellaneous service or item being billed. Services must meet benefit coverage along with medical necessity guidelines appropriate to the procedure/service. Some procedures/services that are billed with an unlisted code may require prior authorization for coverage determination and benefit eligibility.
What is HCPCS billing?
Healthcare Common Procedure Coding System (HCPCS) are billing codes developed by the Centers of Medicare and Medicaid Services (CMS). They are assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services.
What form do you use to report an unlisted code?
An unlisted code should be reported using the standard CMS-1500 form. Today, Medicare and most payors require that the CMS-1500 form be submitted electronically to facilitate expedient claim submission and, in a best-case scenario, expedient reimbursement.
What are the attachments for a medical claim?
Common attachments include a cover letter, Certificate of Medical Necessity, discharge summary, and/or operative report. These attachments are sent with the original claim, either electronically or by fax, e-mail, or hard copy based on the payor’s rules. After the claim has been submitted, it is important to review the Explanation ...
Can a CPT code be unlisted?
If no specific CPT or HCPCS code exists, then the procedure must be reported using an appropriate “unlisted” CPT code. Some coding staff and surgeons are under the misconception that unlisted codes equate to unpaid codes. However, unlisted CPT codes, when reported with appropriate documentation, should be reimbursed.
Does Medicare assign CPT codes?
Medicare does not assign a value to CPT Category III codes. Hence, they should be reported the same way that unlisted codes are reported. When seeking reimbursement for a surgical procedure, it is important to select the Current Procedural Terminology (CPT)* code or Healthcare Common Procedure Coding System ...
Do you report an unlisted procedure?
Reporting an unlisted procedure typically requires more steps before and after the procedure than reporting a procedure that has a specific CPT or HCPCS code. To lessen the chance of payment denial for elective cases, it is best to obtain prior authorization in writing from the payor before performing an unlisted procedure.
What happens if you don't submit an unlisted code?
The unlisted code will be denied as a billing error. Medicare payment will be based on the information submitted. If the required information is not submitted, any unlisted procedure or service will be denied as unprocessable.
What is the responsibility of the provider to ensure all information required to process an unlisted procedure or NOC code is included
It is the responsibility of the provider to ensure all information required to process an unlisted procedure or NOC code is included on the CMS-1500 form or the electronic media claim (EMC) when the claim is submitted. If required information is missing, the code will be deemed unprocessable.
