The Dreaded Unlisted Procedure Code

We have all been there before; reviewing an extensive OP report/procedure note only to realize (typically after a great deal of time is spent researching) there is no CPT code that fits the service provided. Now it is time to use the dreaded unlisted code to report the procedure performed. Just simply hearing “unlisted procedure code” will make a coder/biller/provider cringe when it comes to having to apply it to services performed.

Following these 3 simple steps will alleviate some of the anxiety when it comes to using an unlisted procedure code:

1. An unlisted procedure code should only be utilized when all other options are exhausted. If it is determined after thorough review of all CPT codes (category I or III codes) that there is no established CPT code fitting the procedure performed, it is time to utilize the unlisted procedure code. With this being said keep in mind that it is not part of the “correct coding initiative” to pick a code that closely represents the procedure performed instead of using the unlisted procedure code.

2. Utilizing an unlisted procedure code also comes along with the requirement of submitting additional documentation to support the service performed. Per CPT instructions “A service or procedure may be provided that is not listed in this edition of the CPT codebook. When reporting such a service, the appropriate ‘Unlisted Procedure’ code may be used to indicate the service, identifying it by ‘Special Report’”. This special report should incorporate the following: a sufficient description or explanation for the need of the procedure, as well as a listing of any necessary tools/equipment to provide the service. Along with the special report there should also be a document that further explains the procedure in great detail in laymen’s terms (try to steer clear of difficult medical terminology), including any pictures or diagrams to help explain the extent of the procedure.

3. Lastly a fee will need to be applied to the unlisted code. The best way to determine a fee for an unlisted procedure would be to compare the procedure performed to a “listed” procedure; keeping in mind things such as the work put into completing the procedure, amount of time, patient risk, supplies, etc. Make sure to reference the “listed” procedure in your special report (step 2) and explain why the two procedures are similar and therefore should have a similar fee. One last thing to remember, unlisted procedure codes do not have a set global period as “listed” procedure codes do. With that in mind it would be beneficial to make reference to a global period of a similar procedure as with the fee.

These 3 quick tips should help elevate the anxiety that comes with billing an unlisted procedure code. Check back with Medorizon for more helpful billing tips and tricks and all of your other medical billing needs.

Source: https://www.aapc.com/blog/44959-unlisted-procedure-codes-3-tips/