Claims for unlisted procedure codes are considered on a case-by-case basis, but insurers often determine payment based on the documentation coders provide.
Wondering about unlisted codes and why they are there after all? Many coders think passively as far as unlisted procedure or service is concerned, assuming – or hoping – they would not have to encounter a case that needs the use of such codes.
As a coder, however, you should not be caught off guard when you’re suddenly faced with a case like the following:
A 58-year-old woman presented with a gastrocutaneous fistula that had persisted for 5 months following the removal of an endoscopically-placed gastrostomy tube. Her doctor in a private hospital decides to do something about it and uses a clip to close the gastrocutaneous fistula.
AMA’s Instructions for Use of the CPT codebook says, “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.”
In simple terms, this means that you are forbidden to claim unlisted procedure codes unless existing CPT Category I or Category III codes do not describe the procedure you wish to report.
HINT: Always think of the phrase’ accurately describes the service performed.
Your clue to identifying unlisted procedure codes is that many of them end with the final two digits “99”, (e.g. 15999 Unlisted procedure, excision pressure ulcer). Also, they are usually located at the end of each section or subsection of the CPT codebook.
Sometimes you’d think an unlisted procedure or service code is warranted on a claim only to realize later that it can be better represented using a specific procedure or service code by appending a modifier.
Another option you can explore is if a claim can be reported by using CPT Category III codes, which describe emerging technologies and allow for data tracking.
Unlisted procedure or service codes do not provide clear information about the service or item being billed. For this reason, the insurance would often require additional information to accompany claims for any service or item being billed.
If you’re billing a surgery, you would be required to submit an operative report.
If the service you’re billing is a diagnostic test, you should include clinical notes describing the patient’s diagnoses, the test performed and the results of the test.
If it’s a DME item that you’re billing, include the name of the item, a description, the manufacturer, product number and a copy of the invoice.
Lastly, if the service is a drug, you should list on the claim the NDC number of the drug and dosage information. For example, if billing J3490 Unclassified drugs for Diltiazem Hydrochloride extended release, include the drug’s NDC code: 68682-367-90 and dosage: 120mg/1.
How About Using Modifiers?
Can you use modifiers with unlisted codes? The answer is a big NO. Think about why appending a modifier to an unlisted code is not appropriate: modifiers are used to indicate that a service or procedure had been modified by some specific scenario, but not changed in its very definition.
One fact about unlisted codes is that they do not describe a certain service or procedure. So why utilize modifiers with them in the first place?
Coding the Case Example
In the case given at the beginning of this article, you will find that a code for endoscopic closure of gastrostomy does not exist in the CPT codebook. Therefore, you should use the code 43999 Unlisted procedure of stomach to bill the procedure.
It’s also wise to clarify in your documentation that this is an “endoscopic closure”. Otherwise, the payor might return the claim as unprocessable.
Some coders would report the procedure as 43870 Closure of gastrostomy, surgical, which is incorrect because it applies to an open closure of gastrostomy.