Use of Unlisted Codes
FAQs for Unlisted CPT Codes
Q. What is the best way to bill for a procedure when there is not an appropriate CPT® code available?
A. You must use an appropriate unlisted laparoscopic or urological procedure code and equate the procedure to another urological procedure that incorporates the same amount of time, skill and work to complete.
In CPT®'s urology section, these are the available unlisted procedure codes:
51999 Unlisted laparoscopy procedure, bladder 50549 Unlisted laparoscopy procedure, renal 50949 Unlisted laparoscopy procedure, ureter 54699 Unlisted laparoscopy procedure, testis 55559 Unlisted laparoscopy procedure, spermatic cord 53899 Unlisted procedure, urinary system 55899 Unlisted procedure, male genital system 58999 Unlisted procedure, female genital system
Since Medicare will not allow paper claims unless strict requirements are met, all claims must be submitted electronically and a request for further documentation will be sent to offices to support the billing of unlisted codes.
When a request for documentation has been received, use the following guidelines when submitting a claim where there is no specific CPT® code to describe the procedure:
Submit the operative report. To speed up the reimbursement process you should rewrite this report in layman's terms, as the reviewer may not have training in medical terminology. Make sure you include the following:
- the difficulty of the case
- the patient's diagnosis
- the risk of complications
- what was required to perform the surgery
- what was found during the surgery (e.g., the size and location of the lesions, etc.)
- any other problems that the patient may be having and what the follow-up care will be
In addition to the operative report, include a cover letter that states the following:"We have researched the current CPT® Manual and there is no specific CPT® code that adequately describes the procedure performed; therefore, we must submit the unlisted CPT® procedure code, XXXXX. We equate the procedure in time, skill and work involved to CPT® code (have the physician choose a CPT® code similar to the procedure performed)."
Give a brief explanation why the chosen CPT® code is similar to the procedure performed and then bill the amount of the chosen CPT® code. This will guide the claims processor to a better payment decision.
Commercial carriers may have a specific procedure to follow when billing unlisted procedures.
Q. How do you bill for a hand-assisted laparoscopy procedure?
A. There is no special code for hand-assisted laparoscopy procedures. Use the appropriate specific laparoscopy CPT® code for the procedure or the unlisted laparoscopy CPT® codes for the appropriate organ. If there is no unlisted laparoscopy code, use code 53899, Unlisted procedure, urinary system.
Q. My urologist is injecting botulinum toxin, type A into the bladder for spasms. What is the proper way to code for this procedure?
A. There is no specific CPT® code for the injection of botulinum toxin into the bladder. CPT® code 53899 should be used to capture this procedure. The HCPCS code is J0585. Since the use of this treatment is not approved by the FDA, some carriers will not reimburse for this due to its off-label use. Check with the carrier for any specific coverage questions. It may be necessary to have the patient sign an ABN in order to bill the patient for the treatment.
Q. My urologist is performing the Percutaneous Tibial Nerve Stimulation (PTNS). How do I code for this?
A. The AUA has a very clear and rigorous process for requesting review of and granting our official support to new or revised codes proposed by anyone, including industry. Manufacturers must submit all research studies and other evidence available for review to the AUA Coding and Reimbursement Committee (CRC) comprised of physician experts, who are required by the AUA to disclose all of their relationships with industry. In addition, the AUA Coding Hotline staff conducts extensive discussions with other certified coders and consultants before making a recommendation on a choice among codes that may be ambiguous. In the case of PTNS, we all agreed that the procedure being conducted does not completely match the description of CPT code 64555 as printed in the CPT manual. For example, the code descriptor for the 64555 includes an implantation of an electrode. As a result, our advice prior to May to those seeking advice in coding PTNS was to choose between the manufacturer's recommendation (64555) or the unlisted code (64999).
In recent months, with no direct input from AUA, Medicare and other payers have looked more closely at the physician work and practice expense RVU values included in 64555 and have concluded that the procedure commonly conducted by urologists does not include that amount of work or practice expense and therefore, these payers deemed 64555 inappropriate. As you know, in South Carolina, the Medicare carrier has taken what we consider the drastic step of asking for payments back for billing of 64555 by urologists. Due to our concern that our members may be inconvenienced by further reviews and requests for payments, a review of information distributed by the manufacturer and further contact with the American Medical Association was carried out. There was enough inconsistency to officially review this procedure for proper billing practices. The issue was placed on the AUA CRC agenda for the meeting in May. Prior to the May CRC meeting, a workgroup was convened to review all the U.S. peer-reviewed published literature on PTNS. Since the code descriptor for 64555 does not adequately describe the PTNS procedure, the AUA CRC Committee voted that the proper coding should be CPT 64999 unlisted, nervous system. In addition, CRC agreed to review any evidence submitted by the manufacturer that would justify an application for a new code for this procedure within the normal process described above.
So we are advising your members to use the unlisted code 64999 and equate this to a code chosen by your physician that mirrors the work value involved. (We are not recommending any codes). Do not bill out the programming code, there is no programming involved.
Steps in the Claims Process for Unlisted CPT Codes
- Choose an appropriate unlisted code from the correct surgery section of the CPT book.
- Determine the payer's process for claims submission to clarify if they require electronic or paper submission.
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. Often times, 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.