by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 17th, 2016
Using unlisted codes can be quite labor intensive, but if you are prepared and understand ahead of time about using unlisted codes you will have a higher success rate of reimbursement.
- Verify the payers guidelines - Be sure your code selection it is a payable code; if it is not a payable code under the patient’s policy, it is quite possible you will not be reimbursed. That does not mean you do not report it, if it is documented and it happened, it should be reported. Providers are contracted with codes, and if it is not something a policy covers you would need to change the provider contracts and the patient’s benefits and that is not going to happen.
- That does not mean you do not report it, if it is documented and it happened, it should be reported.
- If it is not covered or a payable benefit be sure you have an ABN on file. This requires you to do some verification.
- Define Medical Necessity: If you are not sure what they require to prove medical necessity, ask for a copy of the payers definition.
- Pre-Approval - You may be able to get pre-approval for future visits. The payer may be willing to work with you and give you authorization using another code, (i.e. a dummy code). Reminder: Medicare does not allow for pre authorization.
Some payers require the use of modifier 51 to unspecified codes, or pricing may be calculated from a comparable CPT code. However, the CPT assist (August 2002) states it is not necessary to utilize modifiers as it does not describe a specific service. Again be sure to verify the payers policy. FindACode.com has a payer specific policy tool, you may find helpful, check it out under the TOOLS page.
Always submit supporting documentation - The most important rule in billing when using an unlisted CPT code is to submit supporting documentation! Be sure the details are documented such as, definition of the procedure or product, the nature, extent and the need for the procedure or service. Remember to document time, effort and any equipment needed for the service or procedure. (Required to support medical necessity). You need to be sure the payer can understand what is being requested and what was done.
Make a notation in BOX 19 which code it pertains to, i.e., (see notes attached).
Do not highlight your codes - when/If the payer scans your claim, it may blacken out the code.
Fees and pricing your codes – since unlisted codes do not identify a specific unit value or service they do not have RVU’s, payers most commonly determine payment in comparison to a similar procedure. When pricing your procedures, be sure the comparative code has a similar site, approach and the amount of work and expertise involved. Keep in mind, the payer’s fee schedules will come into play as well, you can only charge the patient the allowable amount of the comparable procedure/code.
Be patient - the claim may be put through a review process and may not get paid as quickly as other claims. If the decision is not in your favor - Begin the appeals process
Appeals - Be sure you have the correct appeals address, it is usually not the claims address.
Submitting Additional Information - Along with documentation you may want to submit a cover letter, this may include but not limited to, the differences between the Unlisted code and a closely related code, used to calculate your fee with supporting justification. Clinical information, any published articles and clinical information, OP reports, the nature of the patients condition and the extent of the work.
This can be quite labor intensive, but if you are prepared and understand ahead of time when using unlisted codes you will have a higher success rate of reimbursement.
Quick, Current, Complete - www.findacode.com