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.
Ask any physician, in nearly any specialty, about prior authorization and the message will be clear: obtaining necessary pre-approvals for physician services is a time-consuming problem. And, as a growing number of private insurers are requiring prior authorizations, it’s only going to get worse.
Prior authorization is a process used by insurance companies or third party payers before they will agree to cover certain prescribed medications or medical procedures. There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied, or an insurance company requiring the patient to go through a separate process to get the service authorized. Such processes could be to have the patient try various medications or other noninvasive services. These services can dictate that a patient must first see unsuccessful results from a medication or service preferred by the insurance provider, typically considered either more cost effective or safer, before the insurance company will cover a different service.
Helpful hints for obtaining prior authorization:
If your office has any questions about a service being authorized, contact the insurer.
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.