Getting paid for unlisted procedures
A: Getting paid for unlisted procedures can be complicated. However, there are several things you can do to increase your chances of reimbursement.
First, call the insurance carrier and ask if they cover the procedure you are about to perform. If they consider it a noncovered service, make sure the patient is aware of this and then recommend the patient call the insurance carrier. Provide the patient with the name and number of the person you spoke with and tell them to ask the insurance carrier for their policy on unlisted and noncovered services.
Even if the insurance carrier does not pay for the unlisted procedure, it’s recommend you bill the insurance carrier anyway. This way, the insurance carrier will see you are providing the service, and the EOB will hopefully show a “patient responsibility” remark code.
Sometimes patients want their insurance carriers billed for unlisted and noncovered services so they know for sure they paid you properly. The “patient responsibility” EOB helps patients become educated on how their insurance carrier processes claims, and it makes it easier for you to get paid directly.
The insurance carrier will often deny the unlisted procedure due to “lack of medical necessity.” In this situation, get the insurance carrier to define “medical necessity.” Request a written definition and review it. You may be able to send in a “pre-authorization” letter in the future.
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Include a lay-term description of the procedure in your letter so anybody who reads it can understand. Try to relate the procedure performed to an existing CPT code as support for reimbursement and explain how your procedure differs. This will show why you didn’t choose an existing code.
CPT code 97039 is a very common unlisted procedure code. Depending upon the service you are providing, 97039 may require direct one-on-one contact for treatment and may be categorized as a constant attendance modality. If you are in-network, contact the insurance carrier to find out their position on 97039 and check the fee schedule — CPT 97039 may be a covered service.
Some of the more common procedures that have been linked to CPT code 97039 are low level laser therapy, mechanical massage, and dry hydro-therapy beds. Again, if you are in-network and performing any of these services, find out if they are covered services. If not, find out if you have to submit the claim for denial purposes and if you can accept payment directly from the patient.
Additionally, ensure the insurance carrier understands the anticipated cost of the care with and without the unlisted procedure. Insurance carriers are always looking to save money. You should tell them how much money you anticipate saving them by minimizing the risk of future, more expensive procedures.
Ultimately, you should always adhere to the AMA official coding guidelines unless your contract with an insurance carrier stipulates otherwise. If you have had difficulty with an insurance carrier processing any unlisted procedure code, then you may address the issue with the provider relations representative who may, in writing, allow you to report a CPT code not following the AMA CPT guidelines.
Marty Kotlar, DC, CHCC, CBCS is the president of Target Coding. Target Coding, in conjunction with Foot Levelers, offers continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, firstname.lastname@example.org or through www.TargetCoding.com.