CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Unlisted procedure coding and documentation requirements

This policy governs submission, documentation, and processing requirements for claims using unlisted CPT, HCPCS, drug NDCs, and DME unlisted codes for Blue Cross Blue Shield - Rhode Island providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyUnlisted procedure coding and documentation requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInclude the completed Unlisted Procedure Claim form and required supporting documentation with all claims filed with an unlisted code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Pendsautomatic claim review behavior

Operative noteoperative note required

11-digitNDC format

InvoiceDME invoice

May denydenial risk

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Unlisted code submission criteria

Submission and documentation requirements for processing claims that use unlisted CPT, HCPCS, drug NDCs, or DME unlisted codes.

ALL of the following

Unlisted procedure codes should be used only when no established code adequately describes the procedure and not for unusually complex or reduced services.
When multiple procedures are performed, services reported with the unlisted procedure must be clearly differentiated from those reported separately.

ALL of the following

All claims filed with an unlisted CPT or HCPCS code must be submitted with the completed Unlisted Procedure Claim form.
Claims submitted without the completed Unlisted Procedure form will deny for documentation.

ALL of the following

Surgical procedures: a copy of the operative note must accompany the claim.
Radiologic and laboratory procedures: a copy of the report must accompany the claim.

ALL of the following

Claims for unlisted and non-specific drug codes require submission of the 11-digit National Drug Code (NDC) in the correct format.
If the NDC is not submitted, the claim will not be processed and will be returned for correction.

ALL of the following

Claims for unlisted and non-specific DME items require submission of the invoice for the item.
Also submit the appropriate unlisted HCPCS code and the completed Unlisted Procedure Claim form.

ALL of the following

Benefits may vary between groups and contracts; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for coverage applicability.

ALL of the following

All claims filed with an unlisted code will pend for review.

Coding & Billing Codes

Unlisted procedure codesmixed

Unlisted CPT and HCPCS codes for procedures where no specific code exists; use only when no established code adequately describes the procedure.

Unlisted drug codesNDCCovered

Unlisted and non-specific drug codes requiring submission of the 11-digit National Drug Code (NDC) in the correct format; claims without the NDC will be returned.

Unlisted DME codesHCPCSCovered

Unlisted and non-specific durable medical equipment HCPCS codes requiring submission of the invoice for the item, the appropriate unlisted HCPCS code, and the completed Unlisted Procedure Claim form.

NDC format — 11-digit NDC required or claim will be returned

Requirement11-digit National Drug Code (NDC) must be submitted in the correct 11-digit format for claims using unlisted or non-specific drug codes; if the NDC is not submitted, the claim will be returned for correction.

Reference listThe Unlisted Drug Code List identifies codes that require submission of an NDC.

Processing consequenceClaims without the 11-digit NDC will not be processed and will be returned for correction.

Provider Filing Requirements & Risks

Prior Authorization

Prior Authorization and Submission

Prior authorization is not required for unlisted procedures. However, all claims filed with an unlisted CPT or HCPCS code will pend for review and must include the required documentation.

Prior authorization: Not applicable
All claims with unlisted CPT/HCPCS codes will pend for review

Denial Risk

Unlisted Form & Denial Risk for Missing Documentation

To ensure correct claim processing, submit the completed Unlisted Procedure (Unlisted Claim) form and supporting documentation with any claim using an unlisted CPT or HCPCS code. Claims submitted without the completed form and required documentation will deny for lack of documentation.

Complete the Unlisted Procedure (Unlisted Claim) form and attach it to the claim
Include a clear definition/description of the procedure and why a specific code is not appropriate
For unlisted surgical procedures: include a copy of the operative note
For unlisted radiologic or laboratory procedures: include a copy of the report
When multiple procedures are performed, clearly differentiate the service(s) reported with the unlisted code from those reported separately
Do not use an unlisted code solely because the procedure was unusually complex or a reduced service

Definitions & Forms

Unlisted procedure / miscellaneous (HCPCS) — definition

DefinitionUnlisted procedure (CPT) or miscellaneous/Not Otherwise Specified (HCPCS) codes are used to report procedures or services for which no specific code descriptor is available; CPT labels these as 'unlisted procedure' while HCPCS may use 'miscellaneous', 'not otherwise specified', 'not otherwise classified', or 'unclassified'.

Appropriate useUse an unlisted code only when no established code adequately describes the procedure; not appropriate for unusually complex or reduced services.

Documentation neededWhen using an unlisted code, provide a clear definition/description of the procedure and explanation why a specific code is not appropriate.

Unlisted Procedure Claim form — required accompanying form

Required formThe completed Unlisted Procedure Claim form must accompany all claims filed with an unlisted CPT or HCPCS code.

Supporting documentationInclude a clear definition/description of the procedure, why a specific code is not appropriate, and pertinent supporting documents (operative note for unlisted surgical procedures; report for unlisted radiology/lab procedures).

Consequences of omissionClaims submitted without the completed Unlisted Procedure form will deny for documentation.

Multiple proceduresWhen multiple procedures are performed, clearly differentiate the services reported with the unlisted procedure from those reported separately.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyUnlisted procedure coding and documentation requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInclude the completed Unlisted Procedure Claim form and required supporting documentation with all claims filed with an unlisted code.

SourceLink

On This Page

OpenPayer

Unlisted procedure coding and documentation requirements

Submission & Documentation Requirements

Coding & Billing Codes

Provider Filing Requirements & Risks

Definitions & Forms