May 17, 2018
Because of rapid advances in healthcare services and related technologies, some procedures or services may not have a specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code. When there’s not a specific code available, coding guidelines specify that you can use an unlisted code, unspecified code, not otherwise specified code, or a miscellaneous code. You’ll also need to include documentation describing the service, per the Unlisted, Non-specific, and Miscellaneous Procedure Codes payment policy.
Documentation should describe or identify services rendered and billed with the unlisted or miscellaneous code, including:
- A clear description of the service performed
- Whether the procedure was performed independently from others or performed at the same surgical site or through the same surgical opening
- Any extenuating circumstances that may have complicated the service or procedure
- Time, effort, and equipment necessary to provide the service
- Number of times the service was provided
If you submit miscellaneous DME (Code E1399) or miscellaneous drugs (J3490 or J3590 for example), documentation must be present in order to be reimbursed.
When you submit all unlisted, non-specific, and miscellaneous CPT and HCPCS codes with documentation, we’ll complete a clinical review and a review for coverage based on the member’s contract (such as for cosmetic, investigational, or medical necessity at the time of the claims submission.)
To avoid denials and delay of reimbursement, always include documentation when submitting an unlisted code.