Unlisted and Miscellaneous Codes
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Defines CareSource Georgia's billing, documentation, and reimbursement requirements for use of unlisted, miscellaneous, NOS/NOC procedure codes and how reimbursement and medical necessity review will be handled; applies to providers billing CareSource Georgia members.
No material clinical or coverage changes in this revision.
Coverage criteria and billing rules
Coverage criteria and billing rules for unlisted codes
Conditions under which unlisted or miscellaneous codes will be considered and reimbursed:
Experimental/Investigational review
- Unlisted/non-specific codes used for procedures deemed experimental or investigational will be reviewed for medical necessity.
Contractual fixed-rate exception
- If unlisted codes are specified at a fixed rate within the provider agreement, those contractual fixed rates will apply.
Unlisted, miscellaneous and comparable codes
| unlisted / miscellaneous / NOS / NOC | Codes used when no specific CPT code adequately describes the service or item |
Pre-service review, documentation, and authorization notes
Pre-service medical necessity review and required submission elements
All unlisted or miscellaneous codes require a medical necessity review prior to service. Providers must submit the unlisted or miscellaneous code(s) with a comparable established code that most closely describes the service; the comparable code must be included with both the medical necessity review request and the claim. Include a statement that no other code is more appropriate and any other information requested by CareSource. Failure to submit a comparable code will result in a claim denial.
- Submit the comparable code with the prior medical necessity review request and on the claim
- Provide a statement that no other code exists that would be more appropriate
- Include any additional documentation requested by CareSource
Authorization does not guarantee payment; post-payment audit
An approved authorization or medical necessity review does not guarantee payment. CareSource may perform post-payment audits to verify code use and, if a more appropriate code is identified, may request recoupment.
- Authorization approval is not a payment guarantee; reimbursement is determined when the claim is processed
- CareSource may verify code use via post-payment audit and seek recoupment if a different code is appropriate
Key definitions
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