Unlisted Procedure Coding: Boost Your Chances Of Payment

You shouldn't choose a CPT code that merely approximates the service provided. This rule is important for compliant coding, however it leaves you with the tough job of submitting a claim without a procedure-specific code. Boost your chances of getting the payments by heeding these advice: You should suggest a proper fee for the service
 
Since unlisted procedure codes don't appear in the Medicare Physician Fee Schedule, they don't have assigned fees or global periods. Your payers will normally determine payment for unlisted procedure claims based on the documentation you provide.
 
You can suggest a fee by making a comparison of the unlisted procedure to a similar, listed procedure with an established reimbursement value. Experts say it helps put your service in perspective with something reviewers are familiar with. 

But the best choice would be: Rather than leave it up to the insurer to figure out which code is the nearest to what your physician carried out, you should explicitly make reference to the nearest equivalent listed procedure. In any case, the treating physician is well-equipped to make this determination. 

Inform the carrier how the procedure you are coding for compares to and differs from the assigned procedure code.  

You should answer these questions: 

a) Was the unlisted procedure more or less difficult than the comparison procedure?
b) Did it take more time to complete; and if it did by how much?
c) Was there a greater risk of complication?
d) Will the patient need a longer recovery and more postoperative attention?
e) Did it call for special training skill or equipment?

You should not let denials go without appeal 
 
This is a known fact that even the best documentation will not always get the payment your radiologist deserves for an unlisted procedure. If the payment isn't proper, you may need to appeal. Make an effort to find out where your unlisted claim is going. See to it that you get the name and department so that you can follow up on your request. 


What you should do: When your radiologist over and over again performs the same type of unlisted procedure, prepare an information file so you do not have to reinvent the wheel every time you submit a claim. Each time you are denied a similar claim, you'll already have an appeals packet ready to send the payer to defend your claim.