CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP035

Unlisted/Not Otherwise Classified (NOC) Coding Policy

Governs billing and documentation expectations when providers submit unlisted (NOC/NOS/NEC) CPT or HCPCS codes for drugs, supplies, services, or procedures when no specific code exists; applies to providers submitting claims to Blue Cross Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyUnlisted/Not Otherwise Classified (NOC) Coding Policy

Policy CodePolicy CPCP035

Change TypeNo material change

Effective DateSep 13, 2024

Next Review Date

Key ActionProviders must include supporting documentation when billing an unlisted code and follow CMS-1500/UB-04 submission requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

supporting documentation requiredwhen an unlisted code is billed

1unit reporting

examplesexamples listed

Item 19CMS-1500 requirement

Documentation & Billing Requirements for Unlisted Codes

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Documentation and billing requirements for unlisted codes

Unlisted code submissions must be accompanied by supporting documentation and meet service‑specific documentation and billing rules; the Plan may request documentation and may deny claims if a more appropriate code exists.

Supporting documentation must be submitted when an unlisted code is billed; failure to adhere to billing and coding policies may impact claims processing and reimbursement.

Provide an accurate and complete description of the drug, service, or procedure; include all related information supporting administration; include invoice for unlisted DME/supply codes; include NDC qualifier, number of NDC units, and NDC unit of measure; state whether the item was provided separately from other services.

Unlisted CPT/HCPCS codes unit value must be reported as one (1).

Use the most specific unlisted code available; do not use a general unlisted code when a category‑specific unlisted code applies.

CMS‑1500 claim forms (or electronic equivalent): include description of the unlisted code in Item 19 (attach additional documentation if description does not fit); include the procedure code in Item 24D (narrative description may be included in Item 19 if needed).

UB‑04 institutional outpatient claims: for unlisted drug codes include the drug name and/or NDC number in Box 43.

The Plan reserves the right to request supporting documentation; if a more appropriate code exists the claim may be denied and a corrected claim with the appropriate code should be submitted.

Service‑type specific documentation (examples)

Anesthesia: Special report with adequate definition/description of nature, extent, and need; time; effort; equipment necessary to provide service.
Imaging/Radiology: Diagnosis and imaging report including test(s) and results.
Lab/Pathology: Lab/pathology report (CMS‑1500 Item 19 must include specific test name(s) or short descriptor).
Medical Service/Procedure: Office notes and any relevant reports documenting the service.
Surgical Procedure: Description of extent and need for the procedure; operative or procedure reports and office notes; explanation why a standard coded CPT is not appropriate; provide a comparable CPT/HCPCS service and, where applicable, comparable RVU or percentage.

Example Unlisted Codes and Unit Reporting

Example unlisted codesCPT | HCPCS | mixed

J9999	Not otherwise classified, antineoplastic drugs
J3590	Unclassified biologicals
J3490	Unclassified drugs
J7999	Compounded drug, not otherwise classified
C9399	Unclassified drugs or biologicals
A9999	Miscellaneous DME supply or accessory, not otherwise specified
E1399	Miscellaneous Durable Medical Equipment (DME)
01999	Unlisted anesthesia procedure (example)
76999	Unlisted ultrasound procedure (example)
99499	Unlisted E/M service (example)

Unlisted CPT/HCPCS units and billing requirements

RequirementUnlisted CPT/HCPCS codes must be reported with a unit value of one (1).

Claim form detail (CMS-1500)CMS-1500 (or electronic equivalent) must include the description of the unlisted code in Item 19; if it does not fit, submit an attachment.

Procedure code field (CMS-1500)Item 24D must include the procedure code (no description). If an unlisted procedure code is in Item 24D, include a narrative description in Item 19.

Institutional outpatient requirementFor UB-04 outpatient claims using an unlisted drug code, provide the drug name/NDC in Box 43.

Key Terms

Unlisted / NOC — definition and related terms

DefinitionUnlisted code: codes identified by terms such as Non-Specified, Not Listed, Not Elsewhere Specified (NEC), Not Otherwise Classified (NOC), Not Otherwise Specified (NOS), Unclassified, Unlisted, or Unspecified.

When to useUse an unlisted code only if no specific CPT or HCPCS code exists; unlisted codes are a last resort and should not be used when a more appropriate code is available.

Supporting informationWhen billing unlisted drug codes, include NDC qualifier (N4), 11‑digit NDC, NDC unit of measure, HCPCS/CPT units, and NDC unit quantity (up to three decimals); NDC must be active for date of service.

Examples of related termsRelated descriptors found in code descriptors include: Not Otherwise Classified (NOC), Not Elsewhere Specified (NEC), Not Otherwise Specified (NOS), Unclassified.