CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Use and submission requirements for unlisted CPT/HCPCS procedure and supply codes

This reimbursement policy governs how providers must report and document services, drugs, and durable medical equipment billed with unlisted CPT or HCPCS codes to Blue Cross Blue Shield of Rhode Island; it affects physicians, facilities, and billing staff submitting claims to BCBSRI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyUse and submission requirements for unlisted CPT/HCPCS procedure and supply codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Unlisted Procedure Claim form and required supporting documentation (operative note, reports, 11‑digit NDC, or invoice) with claims billed using unlisted CPT/HCPCS codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Unlisted Procedure Claim formadministrative requirement

NDC 11-digitdrug requirement

InvoiceDME requirement

Pend/denyconsequence

Coverage and Submission Requirements

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Unlisted code coverage and submission criteria

Coverage and claim processing for unlisted CPT/HCPCS codes depend on member-specific benefits and complete submission of required documentation. Claims submitted without required documentation will pend, deny, or be returned for correction.

ALL of the following

Verify member benefits and contract-specific coverage in the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before assuming coverage
BCBSRI may revise this policy at any time; benefits and eligibility are determined by subscriber agreements which supersede this policy

Do not use an unlisted code when an established specific code adequately describes the procedure; unlisted codes are not appropriate solely because a procedure is unusually complex

Documentation required with claim

Submit the completed Unlisted Procedure Claim form with every claim billed using an unlisted CPT or HCPCS code
Provide a clear definition/description/name of the procedure and an explanation why a more specific code is not appropriate
Procedure-specific supporting documentation
- For unlisted surgical procedures, include a copy of the operative note
- For unlisted radiologic and laboratory procedures, include a copy of the report

Drug-specific submission rule

For unlisted and non-specific drug codes, submit the 11-digit NDC in the correct format; if the NDC is not submitted the claim will be returned for correction and not processed

DME-specific submission rule

For unlisted and non-specific durable medical equipment items, submit the invoice for the item, the appropriate unlisted HCPCS code, and the completed Unlisted Procedure Claim form

Codes and Coding Requirements

Unlisted codesmixed

unlisted CPT/HCPCS

Unlisted procedure codes used when no specific code exists; includes unlisted surgical, radiologic, laboratory, drug (unlisted NDC-required), and DME items (invoice required).

NDC format requirement - unlisted drug codes

RequirementSubmission of the 11‑digit National Drug Code (NDC) in correct 11‑digit format is required for claims billed with unlisted or non‑specific drug codes.

Consequence of omissionIf the NDC is not submitted, the claim will not be processed and will be returned for correction.

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

Provider Billing and Submission Actions

Prior Authorization

Submit completed Unlisted Procedure Claim form and supporting documentation or claim will deny/pend

Prior authorization is not applicable; however, claims submitted with an unlisted CPT or HCPCS code must include the completed Unlisted Procedure Claim form and required supporting documentation (operative note for surgical unlisted procedures, report for radiologic/laboratory unlisted procedures). Claims submitted without the completed Unlisted Procedure form will deny for documentation or be returned for correction. Provide a clear definition/description of the procedure and explain why a more specific code is not appropriate; when multiple procedures are performed, clearly differentiate the service(s) reported with the unlisted code from services reported separately.

Complete and attach the Unlisted Procedure Claim form with the claim.
Include operative note for unlisted surgical procedures; include the report for unlisted radiologic or laboratory procedures.
Explain why no specific code adequately describes the procedure and clearly define/describe the service.
Differentiate services billed with the unlisted code from other separately reported services.