CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP035

Unlisted/Not Otherwise Classified (NOC) Coding Policy

Governs billing, documentation, and reimbursement expectations when providers report unlisted (NOC/NEC/NOS) CPT or HCPCS codes for drugs, supplies, services, or procedures for BCBS Oklahoma members; applies to in-network and out-of-network professional providers and facilities.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyUnlisted/Not Otherwise Classified (NOC) Coding Policy

Policy CodePolicy CPCP035

Change TypeNo material changes

Effective DateSep 2, 2022

Next Review Date

Key ActionSubmit supporting documentation describing the drug/service/procedure and medical necessity when billing an unlisted CPT/HCPCS code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

In‑Network & Out‑of‑Networkprovider applicability

Supporting docs requireddocumentation requirement

1unit reporting

Denial/reassignment possibledenial risk

2022-09-02effective date

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Unlisted Code Coverage Criteria

Unlisted Code Documentation and Billing Criteria

Documentation and billing criteria the Plan requires to consider reimbursement for unlisted codes.

Submit supporting documentation describing the drug, service, or procedure and medical necessity.

Include an accurate and complete description of the drug, service or procedure; all related information to determine medical necessity; and any information about whether the service was provided separately from other services.

For unlisted DME/HCPCS codes include a narrative/description on the claim with item name, manufacturer and product number (UPN) and, if applicable, a copy of the invoice.

For unclassified/unlisted drug codes include NDC qualifier (N4), 11-digit NDC billing number (no spaces or hyphens), NDC units and unit of measure, and ensure NDC corresponds to date of service; list one unit in SVI/CMS fields and do not quantity bill NOC drugs unless directed.

Report unlisted CPT/HCPCS unit value as one (1).

Include description of the unlisted code on the CMS-1500 claim form Item 19 (or electronic equivalent); include procedure code in Item 24D and a narrative in Item 19 if needed; for institutional outpatient use UB-04 Box 43 for drug name/NDC when applicable.

Use the most specific unlisted code available (do not substitute a less-specific unlisted code when a more specific unlisted code is appropriate).

Provide specific supporting documentation by unlisted code category as applicable (examples): anesthesia — special report with definition/description, time, effort, equipment; imaging — diagnosis and imaging report; lab/pathology — lab/pathology report; surgical — operative/procedure reports and explanation why standard CPT is not appropriate and comparable CPT/RVU information.

The Plan may deny or reassign payment if a more appropriate specific code exists; claims are reviewed case-by-case and the Plan may request additional documentation.

When applicable, include the following category-specific items:

Anesthesia unlisted: special report detailing nature, extent, need, time, effort, and equipment.
Imaging/Radiology unlisted: diagnosis and imaging report including tests and results.
Lab/Pathology unlisted: lab/pathology report; Item 19 of CMS-1500 must include specific test name(s) or short descriptor.
Surgical unlisted: description of extent and need, operative/procedure reports, office notes, explanation why standard CPT is not appropriate, and comparable CPT/HCPCS service code(s) with RVU or percentage comparators.

Coding Examples and Billing Rules

Examples of unlisted codes by categoryCPT | HCPCS

01999	Unlisted anesthesia procedure (example)
76999	Unlisted ultrasound procedure (example)
86849	Unlisted immunology procedure (example)
96999	Unlisted dermatological service or procedure (example)
95999	Unlisted neurological or neuromuscular diagnostic procedure (example)
48999	Unlisted pancreas surgery procedure (example)
A9999	Miscellaneous DME supply or accessory, not otherwise specified (example)
E1399	Miscellaneous Durable Medical Equipment (DME) (example)
J3490	Unclassified drugs (example)
J3590	Unclassified biologicals (example)

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Unlisted CPT/HCPCS units

Unit reporting requirementReport unlisted CPT/HCPCS codes unit value as one (1).

Claim form guidanceList one unit of service in the 2400/SVI-04 data element or Item 24G of the CMS-1500 form or field 46 of the UB-04. Do not quantity bill CPT/HCPCS units for NOC drugs/biologicals unless otherwise directed.

NDC and unit linkageWhen billing unclassified/unlisted drugs, submit the NDC with the accurate HCPCS/CPT code(s) and the number of HCPCS/CPT units; NDC units must reflect the quantity administered and the NDC must be active for date of service.

Decimal precision for NDC unitsThe Plan will accept up to three decimals in the NDC units field; failure to include appropriate decimals may lead to incorrect payments subject to review or audit.

Provider Actions and Reminders

Prior Authorization

Prior Authorization Reminder

Some services or procedures require prior authorization; providers should consult the Plan's prior authorization list and other Plan documents before submitting claims.

Definitions

Definition: Unlisted code

Definition (concise)An unlisted CPT or HCPCS code is used only when the procedure, service, drug, or supply is not adequately described by an existing specific code.

Synonymous termsNon-Specified; Not Listed; Not Elsewhere Specified (NEC); Not Otherwise Classified (NOC); Not Otherwise Specified (NOS); Unclassified; Unlisted; Unspecified.

Use conditionUse unlisted codes only as a last resort when no more appropriate specific procedure or service code exists.

Documentation requirementWhen submitting an unlisted procedure code, supporting documentation must be submitted; the Plan reserves the right to request supporting documentation.