Unlisted CPT codes, drugs and supplies billing

We pay claims for procedures without an associated CPT code ONLY if you provide enough additional information for us to understand the circumstances and process the claim.

Practitioner billing for unlisted procedures

To get claims for unlisted codes processed on the first submission:

1. Identify the unlisted procedure using the Unlisted code explanation form.
2. Flag your documentation. Underline, star or flag (DO NOT HIGHLIGHT) the portion of the medical record that describes the procedure you are billing.
3. Provide a comparable CPT (when possible). This provides us with detailed information regarding comparable services. In your letter or notes, include a brief reason outlining why this is a comparable service (e.g., same procedure performed on different bone; same procedure but different ligament with higher complexity).

Facility billing for unlisted procedures

To get claims for unlisted codes processed on the first submission, beginning May 1, 2018:

1. Identify the unlisted procedure by supplying a note describing what item or service was supplied. Use the note segment: NTE - Third-party Organization Notes in the electronic claim, or the FL80 remark section of the paper UB-04.
2. Provide a comparable CPT (when possible). This provides us with detailed information regarding comparable services.

Billing for other unlisted services

• Unlisted drugs: Make sure to provide the name of the drug, NDC and the dosage. Providing an invoice is not always needed if you provide this information.
• DME, P&O, or other supplies: Include the name of the item, the manufacturer, and specific information on why you're using an unlisted HCPCS code.

Contact the Provider Helpline at 800.942.4765, option 2, with questions.