Adding a Description for Unlisted Procedure Codes

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 the following may be used in these situations:

• Unlisted code
• Unspecified code
• Not otherwise specified code
• Miscellaneous code

These codes usually end in XXX99 and are located at the end of a code section in both CPT and HCPCS codebooks.

Since these procedure codes don’t provide a specific description of the actual service provided, per Premera payment policy guidelines, a description of the service performed must be included on the claim. This description can be submitted in one of two ways, either on the claim line submitted with the unlisted code (Box 24) or included as free form text in box #19 on the Professional claim form (example below):

Regardless of the charge amount for the unlisted service, a description of the service being submitted with an unlisted procedure code must be provided. Failure to supply such a description in either of the two locations noted above will result in the claim being denied reimbursement for additional information.

Sign into your Availity account to review the payment policy for unlisted codes (cmi_168163) and for further details on documentation required to support the submission of the unlisted code.