Group 1 Paragraph. Most payors have a prior authorization form that allows the surgeon to describe the planned procedure and the medical necessity of the operation. Always submit supporting documentation - The most important rule in billing when using an unlisted CPT code is to submit supporting documentation! Also note how the unlisted procedure differs from the next-closest listed procedure. For all their complexities, submitting claims with unlisted codes will help keep you compliant and alert to the need for new CPT codes. This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes. Understandably, coders may require additional information from the medical records before determining whether to use the unlisted code for this procedure, including operative reporting that details the surgical approach to the SI joint. To support your charge, it is recommended that you attach a cover letter. Vol. Provide a description in the 2400/SV101-7 data element. Billing tips for CPT cod C9399 Policy: Beginning January 1, 2004, hospital outpatient departments may bill for new drugs and biologicals that are approved . She is the founder and past president of the Washington, D.C., local chapter and is currently a member of the Charleston, S.C., local chapter. Would you happen to know where I could get information on the correct way to bill Plastics and Reconstruction surgeries. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. Therefore, you have no reasonable expectation of privacy. A service or procedure may be provided that is not listed in this edition of the CPT codebook. Report an unlisted code only once. If no specific CPT or HCPCS code exists, then the procedure must be reported using an appropriate unlisted CPT code. Having a full year to make payments without interest is very attractive when patients are considering surgery, Ms. Whitten said. Part A/B rebilling is performed in a case where the patient did not meet inpatient criteria. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. We are looking for thought leaders to contribute content to AAPCs Knowledge Center. Use these characters to include a concise description of the unlisted procedure code. Unlisted Codes: Background and Billing. An existing code should not be selected if it merely approximates the service provided. This website and its contents may not be reproduced in whole or in part without written permission. Unlisted procedure codes are identified as XXX99 or XXXX9 codes and are located at the end of each section or subsection of the CPT codebook. var url = document.URL; In order for TriWest to make an appropriate benefit determination, prior authorization for all unlisted codes is required. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Coverage Determinations (LCDs), training material, publications, and Medicare guidelines, internally within your organization within the United States for the sole use by yourself, employees and agents. An unlisted code represents an item, service, or procedure for which there is no specific CPT code (including Category II and III codes). The physician does the surgery, and then payment gets denied dueto it being deemed experimental/investigational or lacking medical necessity.. When billing for unlisted drug codes J3490 and J9999 you must indicate the name, strength, and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in theANSI 837 claim file). It's a lot more efficient." For Medicare patients, if the unlisted procedure performed is one that other surgeons may perform in similar clinical circumstances, it would be helpful to share this information with the surgical representative on the Medicare Contractor Advisory Committee (CAC). Below is an example of a case study of a minimally invasive surgical (MIS) sacroiliac (SI) joint fusion one of the fastest-growing sectors of the spine and orthopedic procedure market for the last 10 years. var pathArray = url.split( '/' ); The bottom line: Reporting an unlisted procedure or service code requires special effort, but correct coding requires that you use a code that most accurately represents the service performed. Tip 1: Unlisted Procedure Codes Are a Last Resort You should report unlisted procedure codes only when no other Category I or Category III CPT code accurately describes the procedure or service the provider performed. LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE ("NUBC"), Point and Click American Hospital Association Copyright Notice, Copyright 2021, the American Hospital Association, Chicago, Illinois. Examples of CPT Unlisted Codes and Comparison CPT Codes, When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation along with the claim to provide an adequate description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service. Noridian will not correctly code an unlisted procedure or NOC code when a valid code is available. If no such code exists, report the service or procedure using the appropriate unlisted procedure or Not Otherwise Classified (NOC) code (which often end in 99). By Karla VonEschen, CPC. And many of these procedures dont have specific CPT codes, he added.That means physicians must understand payer authorization and coverage policy issues. As a result, obtaining fair reimbursement requires special attention before and after such procedures. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. This policy may apply to the following codes. Next, add in your clinic fee (Billed Amount) like usual. To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. Eliciting the support of the surgery CAC representative provides the opportunity to establish open lines of communication with the CMD to discuss coding and billing issues as they arise, including changes and updates in payment, and other pertinent information between the contractor and medical community. Article Text. 3637, 10-28-16).Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf. The 5010 TR3 Implementation Guide instructs: "Use SV101-7 to describe non-specific . The CPT code book includes a number of unlisted Category I codes, generally found at the end of a section or subsection. clarified billing for unlisted service and existing policy on non-reimbursement of special techniques/equipment; added unlisted codes 89240, A4641 to example . It is inappropriate to report the best fit HCPCS/CPT code unless it accurately describes the service performed, and all components of the HCPCS/CPT code were performed. The CPT instructions for use concur, stating that if a procedure or service is not accurately described by a code, the unlisted code should be used instead. Lack of transparency will cause reputational damage for hitting patients with surprise bills, cautioned Dr. Marks. However, unlisted CPT codes, when reported with appropriate documentation, should be reimbursed. A full listing of unlisted procedure also codes appears in the "Surgery Guidelines" portion of CPT, prior to the 10000-series codes. SomeAAOS Nowarticles are available only to AAOS members. The ADA is a third-party beneficiary to this Agreement. laparoscopic, transnasal, infusion, with clip, type of graft, etc. To support your charge, it is recommended that you attach a cover letter. Example The provider administered 1 mL of Bupivacaine intravenously. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Here are three tips to apply these codes, correctly. This column provides information about reporting an unlisted CPT code. Dr. Marks warned that following the adage close enough is good enough may lead to legal problems with insurers, as inaccurate coding may be considered fraud, abuse, or a false claim. Staff also should educate patients about their anticipated financial responsibilities, obtain waivers of understanding, and collect appropriate payments from patients. These procedures should be properly reported via unlisted coding because they are separate and distinct from 27279 procedures, and so surgeons and professional societies can track and measure their procedural performance. 9 P. 28. Tweets by RadiologyToday The AMA does not directly or indirectly practice medicine or dispense medical services. The Healthcare Common Prodecure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs. Even if the description can be summarized in this small space, it is best to send additional claim attachments. "American Academy of Orthopaedic Surgeons" and its associated seal and "American Association of Orthopaedic Surgeons" and its logo are all registered U.S. trademarks and may not be used without written permission. Enter all or part of a keyword of the procedure in the Look For search box. In the past, unlisted codes had to be billed on paper, explained Dr. Marks. Eye coding examinations make use of 920XX codes. They described in detail the lateral approach, which includes avoidance of complications and risks to the surrounding anatomy. An AOC is rarely eligible for payment if it's the only procedure reported by a practitioner. Why would an unlisted procedure be BY CLICKING ABOVE ON THE LINK LABELED "I Accept", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS. If required information is missing, the code will be deemed unprocessable. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. In medical billing, an unlisted code is used to report a service or procedure that does not have a specific Current Procedural Terminology (CPT) code. The other option in medical billing and coding dealing with unlisted codes is they often end with a 99 and are at the end of the section for a CPT. Choosing a code that is similar but not accurate in order to get paid is not the right thing to do. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Privacy Policy | Terms & Conditions | Contact Us. If the surgical procedure itself is reported with an unlisted code due to the use of a robotic surgical system, the unlisted code will be manually priced base d on the contracted fee or MPA for the listed procedure code for the base surgical . this information is placed after some codes in the cpt manual and contains helpful information. However, other newcomers utilize a posterior (dorsal) approach to the SI joint, which differs not only in surgical technique from the lateral MIS procedure (in terms of surgical steps and time in the operating room), but also in the patient vignette currently described under CPT 27279. Consider these resources the next time a provider asks you whether a new procedure fits within the confines of current coding. Medicare patients must sign an advanced beneficiary notice when services are not covered. LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT"). The responsibility for the content of this file/product is with Noridian Healthcare Solutions or the CMS and no endorsement by the AMA is intended or implied. A signed waiver indicates that you have explained to a patient that he or she will be responsible for payment and, more importantly, that he or she accepts responsibility for payment. Billing/Coding/Physician Documentation Information . when using an unlisted code a(n) - must accompany the claim. California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands. Surgeons Weigh in on 27279 We are following CPt guidelines by reporting an unlisted CPt code, Some coding staff and surgeons are under the misconception that unlisted codes equate to unpaid codes. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established. If the description does not fit in Item 19, providers who submit paper claims should include an attachment to describe the service or procedure. Do not select a CPT code that merely approximates the service provided. third-party payers determine the contents of a surgical package. The payer may create a dummy code for the unlisted procedures or set a fee for the codes to facilitate automatic adjudication. An Add-on Code (AOC) is a Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) code that describes a service that is performed in conjunction with the primary service by the same practitioner. Is the recovery time for the patient longer? The following unclassified drug codes should be used only when a more specific code is unavailable: When submitting a claim using one of the codes listed above, enter the drug name and dosage in Item 19 on the CMS 1500-claim form or the electronic equivalent. Unlisted codes provide the means of Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. It is a good practice to provide flexible payment options for patients who are unable to pay out-of-pocket costs in one lump sum. In the concise description of the procedure, it is helpful to include how the procedure was performed (e.g. In the case of advanced hip procedures, attempting to obtain prior authorization for physician fees will most likely be unsuccessful because, currently, many are noncovered procedures, although many carriers may cover facility fees and inpatient stay services associated with such surgeries. She creates coding and reimbursement guidance for medical device products and procedures, manages the reimbursement side of clinical trials, and works with patient access, as well as coding and auditing for several clients. Regarding a special report, CPT further explains: A service that is rarely provided, unusual, variable, or new may require a special report. When setting fees for an unlisted procedure or service, compare the procedure or service performed with a listed procedure/service that requires similar provider work, resources, patient risk, etc., and reference this procedure/service in your special report (above). Was there a greater risk of complication? 2022 Noridian Healthcare Solutions, LLC Terms & Privacy. Explore This Issue . J3490 is a HCPCS Code. Code descriptors, illustrations, and example vignettes in the CPT code book are intended to help us interpret when to use current coding for new technologies. CPT is a trademark of the AMA. Then, click Find Now and the search results are listed. This system is provided for Government authorized use only. Ms. Whitten said financing gives patients the purchasing power to schedule services and surgeries quickly. All medical billing coders need to submit clear supporting documentation any time they are using unlisted CPT codes. Many surgeons are hesitant to bill for unlisted services out of fear that the procedures will be poorly reimbursedif at all. Reimbursement for these services can be nuanced and complex, but can be navigated with some basic understanding. TIP: AAPC offers many resources on how to use unlisted codes, including guidance on the use of crosswalks and other educational tools. Some procedures may not be found in any level of Healthcare Common Procedure Coding System (HCPCS). Typically, these are services that are rarely provided, or are unusual, variable, or unlisted procedures. List two or three factors that make the unlisted procedure the same work, or more or less difficult than the comparison code. The use of an unlisted code is necessary when the service or procedure differs in a significant enough way from current coding. For The Record. Cheryl Toth, MBA, is director of content development at KZA. If you have done a good job in your operative report, it should clearly state the indications for the procedure, the medical necessity for the procedure, and exactly what was done during surgery that corresponds to the codes submitted.. If the specific analyte is not listed in the more specific CPT. Indicate the normal fee for the comparison CPT code and indicate the fee for the unlisted CPT code based on the percentage of more or less work required and documented in your letter. My clients often come to me with new and exciting medical technologies, which they hope will somehow fit within existing coding. Hence, they should be reported the same way that unlisted codes are reported. In those instances where an unlisted procedure is performed without prior authorization (for example, an urgent operation or unanticipated intraoperative procedure), a copy of the operative report should be submitted, along with supporting information outlining the decision-making process and the medical rationale for performing the operation. When an unlisted procedure or service code is reported, this "report" must accompany the claim to describe the nature, extent, and need for the procedure or service along with the time, effort, and equipment necessary to provide the servie. Machelle T. Morningstar, CPC, COC, CEMC, COSC, is the president of Morningstar Coding and Reimbursement Consultants, a firm that caters primarily to reimbursement in the medical device field. No fee schedules, basic unit, relative values or related listings are included in CPT. Orthopaedic surgeons often perform procedures for which no specific Current Procedural Terminology (CPT) exists. Ms. Whitten sent it to show the patients signature, indicating that the patient understood that the procedure was not covered. Unlike specific procedures, you'll need to add a custom Label to the billing code that describes the service in detail. Surgeons should resist the temptation to use CPT codes that are similar to procedures performed when an unlisted code is more appropriate. CPT 99499 is never to be used to interpolate . According to Ms. Whitten, only a few of NHIs commercial plans have preferred waivers. CPT includes so-called unlisted procedure codes to report procedures or services for which there is no more specific code. If you do not include any additional information, Medicare may deny the claim . In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Orthopaedic surgeons often perform procedures for which no specific Current Procedural Terminology (CPT) exists. When an unlisted procedure or service code is reported, this "report" must accompany the claim to describe the nature, extent, and need for the procedure or service along with the time, effort, and equipment necessary to provide the servie. Privacy Policy | Terms & Conditions | Contact Us. Pricing will be based on the information entered in these fields. It is the responsibility of the surgeon and the coding or billing staff to report unlisted CPT codes appropriately and follow up with payors if a claim is denied. If the required information is not submitted, any unlisted procedure or service will be denied as unprocessable. Bulletin of the American College of Surgeons Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Weve never been successful [in] getting predetermination approval for PAO or labral reconstruction, she said. 1995-2022 by the American Academy of Orthopaedic Surgeons. If two or more procedures that require the use of an unlisted code are performed on different Any of these factors can make a difference in reimbursement. In your cover letter, list 2-3 things that make the unlisted procedure more or less difficult than the comparator CPT code. performed. This example of MIS SI joint fusion provides an excellent guide as to when we should consider new technology under current coding in a fast-growing procedural market. 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