CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Unlisted CPT/HCPCS procedure and supply claims

Governs submission and documentation requirements for unlisted CPT, HCPCS, drug and DME codes for Blue Cross & Blue Shield of Rhode Island providers; applies to BlueCHiP for Medicare and Commercial products where noted.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyUnlisted CPT/HCPCS procedure and supply claims

Policy CodePolicy N/A

Change TypeNo material change

Effective Date04|01|2003

Next Review Date

Key ActionSubmit all unlisted claims with the completed Unlisted Procedure Claim form and supporting documentation; claims without the form will deny.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Pendadjudication handling

Operative noteunlisted surgical procedures

11-digit NDCunlisted drug codes

Invoiceunlisted DME items

Missing formdenial risk

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Unlisted code coverage criteria

Coverage and processing rules for unlisted CPT, HCPCS, drug and DME codes.

All unlisted claims will pend for review and must be submitted with a completed Unlisted Procedure Claim form and supporting documentation; claims submitted without the completed Unlisted Procedure form will deny for documentation.

Provide a clear definition or description of the procedure performed and justification for not using a specific code; when multiple procedures are performed, clearly differentiate services reported with the unlisted procedure from those reported separately.

Do not use an unlisted procedure code when an established CPT/HCPCS code adequately describes the service; an unlisted CPT code should not be used preferentially when a HCPCS code exists unless the HCPCS code is not sufficiently precise (claims may adjudicate as not separately reimbursed (NSR) in such cases).

For surgical unlisted procedures, submit the operative note; for unlisted radiologic and laboratory procedures, submit the report.

For unlisted drug codes, submit the 11-digit National Drug Code (NDC) in the correct format; if the NDC is not submitted the claim will be returned for correction and will not be processed.

For unlisted durable medical equipment (DME) items, submit the invoice for the item along with the appropriate unlisted HCPCS code.

Benefit variation: Benefits and coverage for unlisted services may vary by group/contract; refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.

Codes and Billing Classifications

Unlisted procedure codesmixed

unlisted CPT codes	Use when no specific CPT descriptor exists; must include Unlisted Procedure Claim form and supporting documentation.
unlisted HCPCS codes	HCPCS 'miscellaneous/unspecified' codes used for services without specific HCPCS; prefer HCPCS when available.

Unlisted drug codesNDC

Unlisted drug codes

Require submission of the 11-digit National Drug Code (NDC) in the correct format; claims missing NDC will be returned for correction.

Unlisted DME HCPCSHCPCS

Unlisted DME HCPCS

Require submission of the invoice for the item and the appropriate unlisted HCPCS code.

Submission, Documentation, and Authorization Requirements

Documentation Required

Submission and review requirements for unlisted claims

All unlisted claims will pend for review and must be submitted with the completed Unlisted Procedure Claim form that provides an adequate description of the unlisted procedure and supporting documentation; claims submitted without the completed Unlisted Procedure form will deny for documentation.

Submit the completed Unlisted Procedure Claim form with an adequate description of the service.
Include all supporting documentation required for clinical review.
Failure to include the completed form will result in claim denial for documentation.

Prior Authorization

Prior authorization

Prior authorization is not applicable for unlisted procedure claims under this policy.

Terminology

inv-07: Unlisted procedure codes — definition and explanation of unlisted CPT/HCPCS terminology

DefinitionUnlisted CPT codes specify 'unlisted procedure'; HCPCS uses terms such as 'miscellaneous', 'not otherwise specified', 'not otherwise classified', and 'unclassified' in addition to 'unlisted'.

PurposeDesignated reporting mechanism for services or procedures that do not have an assigned specific code.

When to useUse an unlisted code only when no established CPT or HCPCS code adequately describes the service.

Documentation requirementSubmit sufficient supporting documentation (see Submission and review requirements) to describe the procedure and justify use of an unlisted code.

Coding preferenceIf an appropriate HCPCS code exists, do not substitute an unlisted CPT code unless HCPCS is not sufficiently precise.