July 20, 2017
Because of rapid advances in healthcare services and related technologies, some procedures or services lack specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes.
Coding guidelines for CPT and HCPCS specify that an “unlisted code,” “unspecified code,” “not otherwise specified code,” or a “miscellaneous code” may be used in these situations. These codes usually end in XXX99 and are usually located at the ends of a code section in both CPT and HCPCS codebooks.
Unlisted or miscellaneous codes may be used if there is no existing CPT or HCPCS code. When a new CPT or HCPCS code is created to represent a service previously billed using an unlisted or miscellaneous code, the new code always takes precedence over the continued billing of an unlisted or miscellaneous code.
These codes don't provide a specific description of the service rendered. If one of these codes is used, Premera requires supporting detailed documentation to be submitted with the claim. The documentation should describe the service(s) rendered and performed. This detailed information is reviewed as part of the clinical review of each of these codes, to assist in determining an allowed amount for the service as represented by the unlisted code.
When submitting an unlisted, unspecified, miscellaneous, or not otherwise specified code, include the following information with the submitted claim:
- A clear description of the service performed
- Whether the procedure was performed independently from other services performed at the same time or performed at the same surgical site or through the same surgical opening
- Any extenuating circumstances that may have complicated the service or procedure
- Time, effort, and equipment necessary to provide the service (e.g. an estimation of the relative value units (RVUs) for the procedure), and
- Number of times the service was provided
This information may be found in operative or procedure reports, imaging reports, laboratory or pathology reports, office notes, or a specific narrative of the service/procedure given. If you don't provide this documentation, the clinical review of the code will be delayed, and we won't reimburse the service(s).
Review the payment policy Unlisted, Non-Specific and Miscellaneous Procedure Codes for further details.