Working with Unlisted Codes (02/09)
In each section of the CPT book, there are unlisted codes that pertain to that certain section of the book. As coders, we must approach our physicians to have them assist us in selecting the proper code to equate the unlisted procedure to. In searching for this code, we must keep in mind that we want to select a code that mirrors the work involved.
Steps for Obtaining Prior Authorization or Precertification
Prior authorization, sometimes called "precert" is a form of communication between the physician's office and the payer. The payer often needs to authorize certain procedures that a physician may perform and to do so, the physician's office may need to call or fax the information regarding the procedure over to the payer.
Below are some simple steps in making sure that procedures are correctly authorized.
Steps in the Claims Process for Unlisted CPT Codes
Once your claim has been submitted using the 837 ANSI format, your billing office will receive an electronic confirmation that your claim was received from the payer. Since your office cannot submit attachments electronically, your claim may deny.
If your claim is denied, the billing staff may elect to appeal the denial.
When submitting the claim, complete the CMS 1500 form. In box 19 of the form, your billing staff may want to refer as to what is being performed by the physician. ie., PTNS
If your payer accepts the paper claim, attach all necessary documentation to help in the processing of your claim form.
Determine the payer's appeals process
Often, the payer may request certain documentation from your office in order to process your claim correctly. Some requests may include: letter of medical necessity, copy of the patient's medical history and operative report, identification of a comparable procedure(s) to assist the payer in establishing a payment level, and any other documentation that may aide in the payer overturning their decision.
Once all of the information is compiled, send your appeal according to the appeals process for the payer. Be sure to submit the appealed claim to the correct address. Oftentimes, the payers have a separate address or appeals unit that these kinds of problems must be sent to. Resubmitting the claim to the original address may result in a "duplicate" claim denial.