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CPT and Unlisted Service Codes

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Current Procedural Terminology (CPT) tells us, “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.” The evaluation and management, anesthesia, surgical, radiology, pathology/laboratory, and medicine sections of CPT all contain unlisted codes (codes ending in 99) as options.  

 

If you electronically report an unlisted procedure code, your carrier will reject your claim pending a review of documentation.  When you receive this initial decision from your insurer, you should send a paper claim with a copy of the operative report or chart notes and a short letter referencing a similar procedure comparing the procedure that the physician performed to a similar procedure.

Also, you must assign a fee for the service. The letter should support the reasons why your assigned fee is appropriate.  You may identify the time it took to accomplish the procedure, the level of complexity, and the new technology or techniques that may not currently be addressed by CPT.

If your physician performs this procedure often, consider meeting with your carrier's medical director as well as the medical directors for your non-governmental insurers. Describe the procedure, arrange for its coverage, and negotiate a mutually agreeable fee in advance.