Policy Guideline for provider performed unlisted CPT code

Overview

Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. 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. 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.



Supporting Documentation Requirements


Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit supporting documentation when filing a claim. Pertinent information should include:

• A clear description of the nature, extent, and need for the procedure or service.

• Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening.

• Any extenuating circumstances which may have complicated the service or procedure.

• Time, effort, and equipment necessary to provide the service.

• The number of times the service was provided.

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.


Provider Billing Guidelines and Documentation

• Claims submitted with unlisted procedure codes and without supporting documentation will be denied.
• Please submit paper claims for unlisted procedure codes. Electronic claims for unlisted procedure codes may be denied, as attachments are not accepted electronically at this time.
• Claims submitted with an unlisted procedure code will be denied if determined that a more appropriate procedure or service code that most closely approximates the service performed is available.
• No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code.
• Unlisted procedure codes appended with a modifier may be denied. (Exception: Unlisted codes for DME, orthotics and prosthetics require appropriate NU, RR or MS modifier.)
• When performing two or more procedures that require the use of the same unlisted CPT code, the unlisted code should only be reported once to identify the services provided (excludes unlisted HCPCS codes; for example, DME/ unlisted drugs).


Medical Record Documentation and Physician Queries
Harvard Pilgrim will not accept retrospectively amended medical records or physician queries beyond 30 days from the service date. Harvard Pilgrim considers medical record documentation and/or physician queries upon review as the official record to support services provided for the basis of coverage or reimbursement determination. Clinical documentation or physician queries amended over 30 days from the service will not be accepted to defend reimbursement, increase reimbursement, or consideration of a previously denied claim.