Claims with unlisted CPT codes
Several claims deny each week because of insufficient information to process the unlisted service
(e.g., lack of medical notes, inability to identify unlisted services, etc.). Here are three helpful tips to
get unlisted codes processed on the first submission:
- Identify the unlisted CPT code – Submit a letter or explanation that indicates what the
unlisted service consisted of.
- Flag documentation – Highlight in yellow or flag the portion of the medical record that
describes the service you are billing.
- Provide a comparable CPT (when possible) – Any explanation or letter submitted should
contain a comparable CPT code/service whenever possible. This provides us with detailed
information regarding comparable services. Include a brief reason outlining why this is a
comparable service (e.g., same procedure performed on different bone; same procedure but
different ligament with higher complexity).
In addition to claims for unlisted procedures, consider the tips below for other unlisted services:
- If billing for drugs, make sure to provide the name of the drug, NDC and the dosage.
Providing an invoice is not always needed if you provide this information.
- If billing for unlisted HCPCS codes for DME, P&O, or other supplies, make sure to
include the name of the item and any additional information as to why an unlisted HCPCS
code is being utilized.
If we’re unable to determine what service your unlisted code represents or identify the service within the
medical record submitted, we may deny the claim and request additional information. Contact the Provider
Helpline at 800 942-4765 with questions.
Topics: Billing, Coding
