Written by Brooke Haycraft, CEMC, CFPC, CPC-H, CPC
Sigh. A big red ‘DENIED’ shows up on your unlisted code claim… again. How frustrating! Not only have you already spent a lengthy amount of time combing through your provider’s surgical documentation & deeming that an unlisted code is appropriate, you now need to figure out why this unlisted code is being denied. Does this scenario sound familiar? It probably does, as all seasoned medical coders have found themselves in a similar situation such as this before. If you’re looking to end the denial cycle of the unlisted code, keep reading for some tools and tips from a payor’s point-of-view that will help you get your claim paid the first time, every time!
Coding guidelines state to choose the name of the procedure or service that best represents the service performed; do not select a code that only semi-compares to the services provided. If no such specific code exists, then it would be most accurate to use an unlisted code.
So, after choosing the dreaded unlisted code, how can you ensure that your unlisted code gets reimbursed the first time around? Here’s a few tips of the trade to help get your unlisted code paid—
1. Be prepared. The following should be submitted with your unlisted code—
· ALWAYS submit with supporting documentation of unlisted services provided. This may sound like common knowledge, but you’d be surprised by the amount of claims denied for this basic reason! Bottom line—a $10,000 unlisted code will not be reimbursed without proper chart notes to verify what was done!
· For unlisted codes that do not require pages upon pages of chart notes, such as unlisted HCPCS codes, it is useful to write a brief description of the unlisted code in box 19 of CMS 1500 form. An adequate, one line clarification of a code could be the difference between reimbursement and a denial stamp.
· Is the unlisted code difficult to interpret per documentation available? If so, highlighting, underlining or bolding key portions that support unlisted code will be immensely helpful for payor review. Bringing attention to important phrases and statements will guide the claim evaluator to focus on excerpts that help define the unlisted code.
2. Be payor specific.
We’ve all heard it many times before; check with your private payor’s guidelines and specifications. Here are a few examples of questions to ask regarding unlisted codes—
· “Do you accept modifier 22 on unlisted codes?” Modifier 22 identifies a service that requires significantly greater effort than typically required. Because an unlisted code does not have a specific procedural definition, payors are unable to determine what constitutes increased procedural work.
· “How should modifier 51 be appended when multiple procedures are performed?” Because unlisted codes have no RVU’s (relative value units) per CMS guidelines, appending modifier 51 correctly according to private payor guidelines. Some payors will expect modifier 51 to be applied to the unlisted code at all times due to the ‘0’ RVU’s, while others will calculate RVU’s based on the most comparable CPT code. Be sure to check to see which guidelines they prefer.
Unlisted codes were created for a reason and deserve to be reimbursed. The above tips should help guide your practice away from a big red ‘DENIAL’ stamp and towards to path of reimbursement.