What to Do When Your Index Says, ‘That Code Number is Unlisted, Sir’

spinal surgery coding guidelines, spinal fusion surgery coding, lumbar surgery diagnosis code, back surgery

Yesterday, we talked about how “unlisted” codes can be the best choice when there isn’t a more specific alternative available, especially when following spinal surgery coding guidelines. Here are some more expert tips for explaining why “unlisted” was the best choice to report on your claim, to make insurers more likely to pay without protest.

1.         Focus on clear documentation without complications

When you report an unlisted procedure code, include a separate cover letter explaining exactly what the provider did, in straightforward language. And don’t hesitate to draw pictures — diagrams and photographs illustrating the procedure can help payers more readily understand (and pay). Don’t forget to make note of the time, effort, and equipment required to provide the service.

For example, when you code for spinal hardware injections, CPT® requires you to report 64999 (Unlisted procedure, nervous system). When you submit that claim, include a cover letter that explains that the purpose of the procedure was to diagnose whether the metal hardware implanted in the patient’s spine was causing the patient’s postoperative back pain.

2.         Explain why you opted for ‘Unlisted’

The cover letter should also clearly explain why you’re submitting the unlisted code. Remember, cautions Gregory Przybylski, MD, director of neurosurgery at New Jersey Neuroscience Institute, JFK Medical Center in Edison, unless the physician performed work described in an existing CPT® code, you must use an unlisted code to describe the work the physician did. Make sure the letter of explanation includes the appropriate unlisted code and descriptor, plus citation of any published references, like specific issues of the AMA CPT® Assistant, to support your use of the unlisted procedure.

3.         Include a code that offers a reasonable comparison

Because payers consider unlisted procedure claims case by case, any payment you receive is based on comparing your procedure description to a similar, valid CPT® procedure code with an established reimbursement value. Przybylski suggests choosing a code that’s similar when compared to the unlisted procedure as far as physician work, including a similar approach (anterior versus posterior, or open versus percutaneous) and a similar spinal region (cervical, thoracic, or lumbar), as well as malpractice risk and practice expense. This can help your insurer determine an adequate payment, so look for a CPT® code that covers the nearest, most similar procedure you can find, and describe how your surgeon’s procedure differs from this next-closest one.

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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