Can you explain “unlisted” CPT codes? When does one use an unlisted code and how do we get paid for an unlisted service?
The CPT manual dictates that you must “select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.”1 With the innovative nature of our specialty, it is fairly common that unlisted CPT codes need to be used to report the procedures we perform. Unlisted CPT codes do not describe a specific procedure but are categorized by general anatomic regions, organs or body systems. Typically, the last two digits of the CPT code end in “99,” such as 27299 (Unlisted procedure, pelvis or hip). A full and complete list of the unlisted procedural CPT codes can be found on pages 73 and 74 of the 2020 Professional Edition CPT manual.1 One should choose an unlisted code based on most appropriate anatomic considerations.
Without a specific procedure described by an unlisted code, relative value units (RVUs) are not assigned. Therefore, reimbursement is not typically predetermined. Providers need to work closely with their coding and reimbursement teams to ensure adequate reimbursement. This process will likely require sharing clinical documentation, including detailed information on the procedure performed or intended to be performed, along with supporting literature to justify the efficacy and medical necessity for the procedure. Additionally, it may be helpful to submit information on a comparable, listed Category I CPT code when the claim is submitted. When determining which listed code to use for a comparison, consider not only general procedural techniques involved, but also the time, intensity, effort and equipment needed to perform the procedure. All these elements should also be captured and supported in the documentation of your procedural report when describing the procedure performed to further justify the work performed.
When giving consideration to reporting listed CPT codes in combination with an unlisted CPT code, one should consider what separate and distinct services were provided as described by the listed code(s) versus what would be considered inherent to the procedure being described as unlisted. For example, if a metastatic bone lesion of the pelvis is being treating with radiofrequency ablation, followed by osteoplasty to stabilize the region, one could report 20982 for the ablation and 27299 to represent the osteoplasty. This is justified since the ablation is a stand-alone procedure, separate from the osteoplasty. In this scenario, one could consider using CPT code 22511 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral) as the comparator code for justification and reimbursement purposes. Furthermore, if a bone biopsy was performed as well, one should give consideration to the fact that a bone biopsy is not separately reportable with 22511, therefore the bone biopsy (20225) should not be reported and would be considered a part of reported unlisted code 27299.
Please visit the SIR coding and reimbursement webpage for resources on coding, including a template letter that can be used when reporting unlisted codes, as well as a form to submit your coding questions. sirweb.org/practice-resources/coding-page
References:
- American Medical Association. (2019). CPT Professional 2020 (CPT/Current Procedural Terminology (Professional Edition)) (Revised ed.). American Medical Association.
Disclaimer: SIR is providing this billing and coding guide for educational and information purposes only. It is not intended to provide legal, medical or any other kind of advice. The guide is meant to be an adjunct to the American Medical Association’s (AMA’s) Current Procedural Terminology (2019/CPT®). It is not comprehensive and does not replace CPT. Our intent is to assist physicians, business managers and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is mandatory for proper coding of physician service.
Every reasonable effort has been made to ensure the accuracy of this guide; but SIR and its employees, agents, officers and directors make no representation, warranty or guarantee that the information provided is error-free or that the use of this guide will prevent differences of opinion or disputes with payers. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this manual. The ultimate responsibility for correct use of the Medicare and AMA CPT billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who utilize the information in this guide in a manner inconsistent with the coverage and payment policies of any payers, including but not limited to Medicare or any Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.
