Do and Don't of Unlisted Procedure Coding

Keep this CPT instruction in mind: "Don't choose a CPT code that merely approximates the service provided." This rule is key for compliant coding, however it leaves you with tough job of submitting a claim without a procedure-specific code. Here are some do's and don'ts to increase your chances of getting the payment your practice earned.

Explain the procedure in Layman's Terms

If CPT does not offer a code specific to the service provided, then you should report the appropriate unlisted-procedure code like 37799 (Unlisted procedure, vascular surgery) for vascular sclerotherapy.

When you file a claim using an unlisted procedure code you should include a cover letter stating why you are using the unlisted code. This separate report should explain in simple straightforward language exactly what the physician did.

According to CPT Assistant (http://www.supercoder.com/coding-references/code-connect)(April 2001), you need to submit reporting documentation identifying the specifics of the procedure such as the procedure report when you file the claim. The supplemental documentation should define the service (nature, extent, need) and the time, effort and equipment required. According to CPT Assistant, you may also include the following factors:

Whether the doctor required help to carry out the service

Whether the procedure was independent of other services

Whether the doctor carried out additional procedures at the same site

Number of times the doctor carried out the service at the encounter

Extenuating circumstances that complicated the service.

You may even want to include diagrams or photographs to facilitate the person reviewing your claim better understand the procedure.

Do not try to use modifiers or multiple units

You shouldn't append modifiers to unlisted-procedure codes or try to report them more than once per encounter.

Suggest an appropriate fee for the service

Unlisted procedure codes don't appear in the Medicare Physician fee Schedule, so they don't have assigned fees or global periods. Your payers will generally determine payment for unlisted procedure claims based on the documentation you provide.

You can suggest a fee by comparing the unlisted procedure to a similar listed procedure with an established reimbursement value.