April 2008 Coding Tip (View More 2008 Coding Tips)

Use of Unlisted Codes

The rationale behind unlisted CPT codes is that they should be utilized for services and/or procedures that are performed that do not have an applicable CPT code. Detailed documentation is vitally important when utilizing unlisted CPT codes, especially for physicians and/or freestanding centers that are reimbursed from the Medicare Physician Fee Schedule (MPFS). Although unlisted CPT codes are found on both the Hospital Outpatient Prospective Payment System (HOPPS) and the Medicare Physician Fee Schedule (MPFS) they are not treated equally. In HOPPS most unlisted CPT codes are assigned to APC groups thereby ensuring reimbursement when the unlisted CPT codes are submitted. The scenario on the MPFS is completely different; there are no RVUs assigned to unlisted CPT codes therefore it is normal and should be expected that these codes will be denied payment on the first attempt. Physicians and/or facilities utilizing these codes should be prepared to appeal the denial by submitting their reasoning behind the use of the unlisted CPT code along with the detailed documentation of the service or procedure performed.