15 Feb 2016

Unlisted CPT Codes


When there is no appropriate Category I or III code to describe the service or procedure then we can use unlisted CPT codes.


      [As per CPT Instructions for use of the CPT Codebook, select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. Any service or procedure must be adequately documented in the medical record].


      Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.


      Unlisted CPT codes are mostly ending with 9 or 99 CPT codes found at the end of each section or subsection of the CPT book.


      While filling unlisted CPT codes, we must to include the following documents since the unlisted CPT codes are not describing the specific procedure.

           1.     Description of the service or procedure (Nature, Extent and necessity)

           2.     The number of times the service or procedure was performed.

           3.     Performed along with other procedures on the same day or same site.

           4.     Any complication related to the service or procedure.

           5.     Equipment, time and effort utilized to perform the service or procedure.


      When submitting supporting documentation, designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code. Required information must be legible and clearly marked.


      Coding/Billing Guidelines:


        • Unlisted CPT codes must be submitted as paper claims.


        • Unlisted CPT codes and without supporting documentation would be denied.


        • If any appropriate CPT or HCPCS codes are available in the CPT book then an unlisted procedure code would be denied.


        • No additional reimbursement would be provided for special techniques/equipment submitted with an unlisted procedure code.


        • Don’t use any modifier with unlisted procedure codes. (Exception: Unlisted codes for DME, orthotics and prosthetics require appropriate NU, RR or MS modifier.) 


        • For two or more procedures that require the use of the same unlisted CPT code, the unlisted CPT code should be reported once.