CurrentEmblemHealthPolicy RPC20220028

Unlisted/Unspecified Procedure Codes reimbursement

Defines documentation, billing, and reimbursement guidelines for claims submitted with unlisted or unspecified CPT/HCPCS procedure, drug, and DME codes for EmblemHealth Commercial, Medicare and Medicaid products.

Policy Summary

PayerEmblemHealth

PolicyUnlisted/Unspecified Procedure Codes reimbursement

Policy CodePolicy RPC20220028

Change TypeClarified / Revised / Added

Effective DateMay 1, 2020

Next Review Date

Key ActionSubmit supporting clinical documentation and the 'Claim Submission for Unlisted Procedure or Service Code Special Report' form with claims.

SourceLink

POLICY UPDATE CHANGES

Policy updated to clarify reimbursement.

Updated with links to Unlisted Claims forms and removed embedded documents.

Reformatted and reorganized policy; transferred content to new template with new Reimbursement Policy Number.

Included definition of 'unlisted code(s)' and NOS example CPT 87899 under Laboratory/Pathology.

documentation requiredsubmission requirement

paper claims preferredbilling guideline

comparable codesreimbursement method

category-specificdocumentation by service type

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.

Unlisted code coverage criteria

Claims for unlisted codes require clinical documentation and specific supporting materials; reimbursement is evaluated against comparable codes and provider agreements.

All of the following must be met for reimbursement of unlisted codes:

ALL of the following

Complete clinical documentation must be submitted for all unlisted codes; claims without supporting clinical documentation will be denied.
See required supporting elements below.
Clinical documentation will be reviewed for appropriate coding, existence of a more appropriate code, coverage, reimbursement allowance and prior notification, if needed.

Supporting documentation should include

Complete description of the procedure (including time and equipment necessary to provide the service).
Whether the procedure was performed independent from other services provided or if it was performed at the same site or through the same surgical opening.
Any extenuating circumstances which may have complicated the service or procedure.
The number of times the service was provided.
For unlisted drug codes: NDC number, dose, and route of administration (use Route of Administration abbreviations as appropriate).
For unlisted DME/supply codes: physician order and/or prescription and invoice.

Billing and submission rules

Paper claims are preferred for unlisted procedure codes; electronic claims for unlisted procedures/services may be denied because attachments are not accepted electronically (exception: unlisted drugs).
The 'Claim Submission for Unlisted Procedure or Service Code Special Report' form must be completed and included with the claim (or submitted via the provider portal where available).
Claims submitted with unlisted procedure codes without supporting documentation will be denied.
Claims with an unlisted procedure code will be denied if it is determined that a more appropriate procedure/service code is available.
No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code.

ALL of the following

Reimbursement for claims billed with unlisted/NOS codes is determined based on comparable established codes and/or rates set forth in provider agreements.

Representative Codes, Examples, and Referenced Ranges

Representative unlisted/unspecified codes and examplesmixed

01999	Unlisted anesthesia procedure(s)
19499	Unlisted procedures, breast
76496	Unlisted fluoroscopic procedure
84999	Unlisted chemistry procedure
89240	Unlisted miscellaneous pathology test
81479	Unlisted molecular pathology procedure
87899	Infectious agent antigen detection by immunoassay; not otherwise specified (NOS)
92499	Unlisted ophthalmological service or procedure
G6021	Unlisted procedure, small intestine (example HCPCS)
J3490	Unlisted drugs

1–10 of 14

1/2

CPT/HCPCS ranges referenced (by category)

Anesthesia range00100-01999

Surgical range10021-69990

Radiology/Imaging range70010-79999

Laboratory/Pathology range80047-89398

Medical/Other procedures range90281-99607

Submission, Documentation, and Billing Actions

Documentation Required

Submission and documentation

Submit complete supporting clinical documentation with the claim and include the completed 'Claim Submission for Unlisted Procedure or Service Code Special Report' form. Paper claims are preferred for unlisted procedures because electronic attachments are not accepted; you may, however, submit the required Unlisted form(s) and medical records via the provider portal. Claims submitted without supporting clinical documentation will be denied.

Include a complete description of the procedure, relationship to other services (same site/same opening), and any extenuating circumstances
For drugs include NDC, dose and route; for DME include physician order and invoice (per documentation guidance)
Use the 'Claim Submission for Unlisted Procedure or Service Code Special Report' form with the claim or upload via provider portal

Denial Risk

Denial risk and reimbursement determination

Claims using unlisted/NOS codes may be denied or subject to recoupment if coding or billing guidelines are not followed or if a more appropriate code exists. Reimbursement for unlisted codes is determined by review against comparable established codes and/or rates in provider agreements.

Unlisted procedure codes appended with a modifier may be denied (exceptions: DME/orthotics/prosthetics require NU, RR, or MS modifiers)
When a more appropriate procedure/service code is available, the claim will be denied or recouped
No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code

Definitions and Abbreviations

Unlisted code(s) — definition, examples, and notes

DefinitionUnlisted codes are used when no appropriate CPT/HCPCS code exists; descriptors include 'unlisted', 'unspecified', 'miscellaneous', 'NOS', and many codes ending in -99.

Examples (NOS and -99)CPT 87899 (Infectious agent antigen detection, NOS); CPT 01999 (Unlisted anesthesia); CPT 19499 (Unlisted breast procedure); HCPCS G6021 (Unlisted small intestine procedure).

Documentation noteClaims with unlisted codes require complete clinical documentation and must be supported by the appropriate report (operative/procedure, imaging, lab/pathology, office notes) as applicable.

Route of Administration abbreviations (for unlisted drug codes)

IVIntravenous

IMIntramuscular

POBy mouth (orally)

PRPer the rectum

SLSublingual (under the tongue)

SQSubcutaneous