The healthcare industry continues to evolve with new services, care devices, medications, and treatment techniques being developed each day. These advancements are entering the field faster than ever before. Many of them have new CPT codes affecting their use and applications.
Yet the American Medical Association (AMA) can sometimes take as much as 18 months to 2 years to come out with modified CPT codes and instructions for some of these new advancements. This can lead to a plethora of unlisted codes that still need to meet the crucial task of expediting the process of coding and billing.
At the same time, the AMA insists that all practices and solo practitioners use a correct CPT code anytime the code would accurately describe a provided service. Attempting to use a CPT code as some type of approximation of the service is considered unacceptable by the AMA as well as most private insurance providers and public health institutions. This includes unlisted codes in most cases.
Insurance providers and public health institutions routinely review unlisted CPT codes more thoroughly than regular CPT codes. Of course, this further increases the chances of a claim denial or rejection. Thus this also means that practices need to have well-defined strategies to receive quick coverage approval for potential unlisted CPT codes.
Tips For Handling Unlisted CPT Codes
There are a few things you can do to reduce the risk of suffering a claim rejection or denial when using a new treatment technique, device, or medication that currently doesn’t have a listed CPT code. This includes things like:
Take The Time To Review the Initial Provider Suggestion
A lot of private insurance providers make suggestions or recommendations for how to use an unlisted code for a specific service or medication. They do their best to stay abreast of new developments in the field and often take a proactive approach to making sure that physicians, clinicians, and practitioners have the information they need to correctly use a new unlisted CPT Code.
It’s in your best interest to examine the details they provide. Then make sure that all of your administrative medical billing coders have also reviewed the service carefully. Sometimes, coders will need to inspect the physician’s records for missing information, and it will save everyone time if they are also on the same page with the insurance provider’s recommendations.
Make Sure To Meet All The Technical Requirements
When submitting the initial description for an unlisted CPT Code for service as part of Item 19 on the CMS-1500 claim form, you need to make sure that you are meeting all of the technical requirements. Just keep in mind that the electronic equivalent of this form only offers a maximum of 80 characters to provide a concise description of the unlisted procedure code.
A lot of physical submissions are unable to describe everything in Item 19. In a case like this, you might also need to attach a document with additional details. Then if you need to submit two or more of the same unlisted CPT code, you will only have to report the unlisted code a single time!
Industry Best Practices For Submitting an Unlisted CPT Code
Most private insurance payers and public health institutions want you to answer a few key questions in advance of using an unlisted CPT code in a claim submission. This includes critical information such as:
The Service Description explains why it was necessary, and to what extent the service was performed.
Any Extenuating Circumstances that notably affected the procedure, or service that was performed.
Important Surgical Details where other service providers might have been involved in the surgical procedure. This includes information on whether it was performed through the same surgical opening and in the same surgical field.
All Pertinent Technical Specifications pertaining to things like how long the procedure or service took. You also need to include detailed information on what equipment and effort were needed to perform. If it was performed more than once, you will also need to note many times the service was provided.
All medical billing coders need to submit clear supporting documentation any time they are using unlisted CPT codes. This includes information that clearly marks what parts of the documentation reference the service that was provided as well as any other critical information. Coders will also need to include information about any specialty providers in the supporting documentation.
Do Unlisted Codes Need Modifiers?
A lot of small practices and solo practitioners will use modifiers when a CPT code is inadequate for accurately describing the details of a service provided to a patient. Though many of these procedures also require modifiers to note any applicable service changes the physician deemed to be necessary for the circumstance. These code modifiers play a critical role in typical medical billing and coding cycles.
Yet unlisted codes don’t require any CPT code modifiers, as unlisted services, by definition, don’t match any fixed described procedure. This means that the AMA expects practices to clearly describe services without using any sort of modifier. If you use a modifier with an unlisted code, it could immediately lead to a claim denial or rejection.
How To Reduce The Risk Of Insurance Claim Denials
The existing coverage standards mean that the majority of insurance payers hold unique rules regarding unlisted CPT codes. However, payer websites often provide relevant submission information. Though you should be prepared to contact payers more frequently when claiming unlisted services otherwise you may receive a claim denial.
Though even with all due diligence, there are still some insurance payers who don’t specifically say whether they cover an unlisted procedure until they receive a relevant CPT code. This is often due to their uniqueness; payers must extensively review unlisted claims before determining coverage status.
Though this also means that some claims submitted with an unlisted CPT code might be denied if the payer organization determines that a more appropriate procedure or service code could have been used. If you are contemplating the use of an unlisted CPT code, it’s always wise to take the time to consult with the patient’s payer institution first. Especially if their coverage requires preapprovals for specialty services.