CurrentAnthemPolicy G-06004

Unlisted or Miscellaneous Codes — Reimbursement

Defines Anthem Blue Cross and Blue Shield HP Medicaid reimbursement rules for unlisted or miscellaneous CPT/HCPCS codes and required documentation for claim review; applies to providers billing Medicaid members in the governed state.

Policy Summary

PayerAnthem

PolicyUnlisted or Miscellaneous Codes — Reimbursement

Policy CodePolicy G-06004

Change TypeTemplate clarificationsno material changes

Effective DateNov 4, 2024

Next Review Date

Key ActionSubmit supporting documentation (written description/office notes/operative report; invoice with item descriptions; corresponding NDC for unlisted drug codes) when billing unlisted or miscellaneous codes.

SourceLink

POLICY UPDATE CHANGES

Policy language clarified and 'Unspecified' removed from policy language during a prior template update.

Policy template updated several times; most recent review approved and effective 11/04/2024 with no changes.

2024-11-04effective date / last approval

Anthem Medicaidpayer / program

3minimum documentation examples

Unlisted/Miscellaneous Code Coverage Criteria

Reimbursement stance and claim review criteria for unlisted/miscellaneous codes:

Anthem allows reimbursement for unlisted or miscellaneous codes unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the diagnosis, service, procedure, or item rendered.

Reimbursement is based on review of the unlisted or miscellaneous codes on an individual claim basis.

Required documentation for claim review

A written description, office notes, or operative report describing the procedure or service performed.

Policy Summary

PayerAnthem

PolicyUnlisted or Miscellaneous Codes — Reimbursement

Policy CodePolicy G-06004

Change TypeTemplate clarificationsno material changes

Effective DateNov 4, 2024

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing, Submission and Documentation Requirements

Denial Risk

Billing and submission requirements / risk

Use industry-standard, compliant coding on all claim submissions. Unlisted or miscellaneous codes should be used only when no established code exists to describe the diagnosis, service, procedure, or item rendered. Failure to follow appropriate coding/billing guidelines may result in claim rejection, denial, recoupment, or adjustment of reimbursement.

Use Current Procedure Terminology (CPT), HCPCS, and/or revenue codes where applicable.
Bill unlisted/miscellaneous codes only when no specific code accurately describes the service or item.
Anthem may reject or deny claims, recover/recoup payments, or adjust reimbursement if coding or billing guidelines are not followed.

Documentation Required

Documentation required for claim review

When submitting claims with unlisted or miscellaneous codes, include documentation to support the service, procedure, item, or drug billed so the claim can be reviewed for appropriate reimbursement.

A written description, office notes, or operative report describing the procedure or service performed.
An invoice with a written description of items and supplies when applicable.
The corresponding National Drug Code (NDC) when billing an unlisted drug code.

Key Definitions

Miscellaneous

DefinitionCodes submitted by a supplier for an item or service for which there is no existing code that adequately describes the item or service being billed.

When to useUse when no established CPT or Level II HCPCS code adequately describes the item or service.

DocumentationBilling with miscellaneous codes typically requires supporting documentation (e.g., description, invoice, clinical notes) for claim review.

Unlisted (HCPCS/CPT)

DefinitionAn unlisted HCPCS code represents an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code.

CPT guidanceUnlisted CPT codes are included at the end of sections or subsections in the CPT code book and are summarized in chapter Guidelines; many end in '99'.

Billing noteWhen using unlisted codes, provide sufficient description in claims so the service can be evaluated during individual claim review.

OpenPayer

Unlisted or Miscellaneous Codes — Reimbursement

Unlisted/Miscellaneous Code Coverage Criteria

Codes and Usage Rules

Billing, Submission and Documentation Requirements

Key Definitions