CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Unlisted CPT/HCPCS procedure and supply claims

Defines submission, documentation, and processing requirements for claims billed with unlisted CPT and HCPCS codes for Blue Cross Blue Shield of Rhode Island; applies to providers submitting professional, facility, drug, and DME claims.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyUnlisted CPT/HCPCS procedure and supply claims

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Unlisted Procedure Claim form with required supporting documentation (e.g., operative note for unlisted surgical procedures) — claims without the form will deny for documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All pendautomatic processing behavior

Operative noteoperative note required

11-digit NDCNDC requirement

Invoice requiredDME invoice

20% reductionpayment adjustment

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Documentation Criteria for Unlisted Codes

Unlisted code coverage and documentation criteria

Submission and documentation criteria for claims billed with unlisted CPT/HCPCS codes:

Require completed Unlisted Procedure Claim form with supporting documentation; claims submitted without the completed Unlisted Procedure form will deny for documentation.

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

ALL of the following

Pertinent information must include a clear definition, description or name of the procedure performed and why a more specific code is not appropriate.
Unlisted surgical procedures: include a copy of the operative note.
Unlisted radiologic and laboratory procedures: include a copy of the report.

When multiple procedures are performed, clearly differentiate services reported with an unlisted code from those reported separately.

Do not use an unlisted procedure code solely because a procedure is unusually complex or is a reduced service; use an established specific code when one adequately describes the service.

ALL of the following

Unlisted 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

Unlisted durable medical equipment (DME) claims require submission of the invoice for the item.
Include the appropriate unlisted HCPCS code and the completed Unlisted form for DME.

Payment note: when only an open CPT exists but the procedure was performed laparoscopically, the approved CPT will be allowed with a 20% reduction of the allowed amount for the service.

Coverage of unlisted codes depends on member benefits; refer to the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits/coverage.

Codes and Coding Requirements

Unlisted codesmixed

unlisted CPT/HCPCS

Codes designating procedures or items without a specific code descriptor; use only when no specific code adequately describes the service.

Unlisted drug codesNDCCovered

Unlisted drug HCPCS

Unlisted or non-specific drug codes that require an 11-digit NDC submission.

Unlisted DMEHCPCSCovered

Unlisted DME HCPCS

Unlisted durable medical equipment codes requiring invoice and completed unlisted form.

NDC length for unlisted drug codes

Required NDC length11-digit National Drug Code (NDC) must be submitted for unlisted and non-specific drug HCPCS codes in the correct format.

Processing consequenceIf the 11-digit NDC is not submitted, the claim will not be processed and will be returned for correction.

Reference listUse the Unlisted Drug Code List to identify codes that require NDC submission.

Submission formatNDC must be submitted in the correct 11-digit format as required on the claim.

Submission, Prior Authorization, and Billing Actions

Prior Authorization

Prior authorization / submission requirements for unlisted codes

All claims filed with an unlisted CPT or HCPCS code will pend for review. Do not use an unlisted code if an established specific code adequately describes the procedure. Submit a completed Unlisted Procedure Claim form plus required supporting documentation (e.g., operative note for unlisted surgical procedures; reports for radiologic/laboratory unlisted procedures). Claims submitted without the completed Unlisted Procedure form will deny for documentation.

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 those reported separately.

Definitions

Definition of unlisted CPT/HCPCS codes

DefinitionUnlisted CPT/HCPCS codes are used for services or procedures without an assigned specific CPT/HCPCS code and should be used only when no established code adequately describes the procedure.

HCPCS terminologyHCPCS unlisted codes may be described as miscellaneous, not otherwise specified, not otherwise classified, or unclassified.

Appropriate useDo not substitute an unlisted code when a specific established code exists that adequately describes the service.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyUnlisted CPT/HCPCS procedure and supply claims

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

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