CurrentFlorida BluePolicy 10-013

Unlisted Procedure Codes

Defines Florida Blue's reimbursement and documentation requirements for professional services reported with unlisted CPT/HCPCS procedure codes and applies to all lines of business and providers serving Florida Blue members.

Policy Summary

PayerFlorida Blue

PolicyUnlisted Procedure Codes

Policy CodePolicy 10-013

Change TypeNo material change

Effective DateJan 26, 2009

Next Review Date

Key ActionSubmit supporting documentation with claims using unlisted procedure codes per CPT guidance, including definition/description, relationship to other services, extenuating circumstances, time/effort/equipment, frequency, and additional clinical detail.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Applies to allPolicy applicability

10-013Policy ID

RequiredDocumentation

Denial listedDenial triggers

Reimbursement Criteria for Unlisted Procedure Codes

inv-01: Unlisted procedure code reimbursement criteria

Reimbursement and denial criteria for claims with unlisted procedure codes

ALL of the following

Deny if specific code exists
- An appropriate specific procedure or service code is available for the submitted service; claims submitted with an unlisted procedure code will be denied if an appropriate procedure or service code is available.
  Reference: CPT guidance to select a specific code when one exists.
Deny if supporting documentation missing
- Supporting documentation is not provided with the claim; claims billed with unlisted procedure codes without supporting documentation will be denied.
  See required documentation details by code range.

Policy Summary

PayerFlorida Blue

PolicyUnlisted Procedure Codes

Policy CodePolicy 10-013

Change TypeNo material change

Effective DateJan 26, 2009

Next Review Date

SourceLink

On This Page

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.

Supporting documentation requirements (by code range)

Evaluation & Management
- Unlisted E/M codes within 99202-99499 require an office or other clinical note.
Surgical procedures
- Unlisted surgical codes within 10004-69990 require an operative or procedure report.
Radiology/imaging
- Unlisted radiology codes within 70010-79999 require the imaging report.
Laboratory/pathology
- Unlisted laboratory/pathology codes within 80047-89398 require the laboratory or pathology report.
Medical procedures
- Unlisted medical procedure codes within 90281-99607 require office notes and reports.
Unclassified drug codes
- Provide the NDC number with full description/name, strength, and service units (see Payment Policy 10-008).
Unlisted DME HCPCS
- Provide a narrative on the claim for unlisted DME HCPCS codes.

Documentation content guidance

Include an adequate definition or description of the nature, extent, and need for the procedure.
Indicate whether the procedure was independent from other services or performed at the same surgical site/through the same surgical opening.
Describe any extenuating circumstances that complicated the service or procedure.
Document time, effort, and equipment necessary to provide the service, and the number of times the service was provided.
Additional items that may be included: complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.

Unlisted Code Ranges, Specific Codes, and Coding Rules

Unlisted code ranges and required documentationCPT

99202-99499	Evaluation & Management unlisted codes; require office or other clinical note
10004-69990	Surgical unlisted codes; require operative or procedure report
70010-79999	Radiology/imaging unlisted codes; require imaging report
80047-89398	Laboratory/pathology unlisted codes; require laboratory or pathology report
90281-99607	Medical procedure unlisted codes; require office notes and reports

Non-CPT unlisted code documentationHCPCS | NDC

Unclassified drug codes	Provide NDC number, full description/name, strength and service units (see policy 10-008)
Unlisted DME HCPCS	Provide narrative on the claim

Multiple procedures using same unlisted CPT

Reporting ruleWhen performing two or more procedures that require the use of the same unlisted CPT code, report the unlisted CPT code only once (excludes unlisted HCPCS).

ExclusionThis single-report rule does not apply to unlisted HCPCS codes (for example, DME or unlisted drug HCPCS/NDC items).

Reimbursement impactIf allowed, a reasonable allowance will be determined by Florida Blue for the unlisted procedure; no additional reimbursement is provided for special techniques/equipment.

Denial conditionClaims billed with unlisted procedure codes may be denied if supporting documentation is not provided or if an appropriate specific procedure code exists.

Submission and Documentation Requirements

Documentation Required

Submit supporting documentation with unlisted procedure code claims

Submit supporting documentation with claims filed using unlisted procedure codes per CPT instructions. Documentation must include an adequate definition/description of the nature, extent and need for the procedure; whether the procedure was independent or related to other services; any extenuating circumstances; time, effort and equipment; number of times the service was provided; and any additional clinical detail (complexity of symptoms, final diagnosis, pertinent findings, diagnostic/therapeutic procedures, concurrent problems, follow-up). Also clearly designate the portion of the report that identifies the test or procedure associated with the unlisted code and include the specific documentation required for the code range (e.g., operative report for surgical unlisted codes, imaging report for radiology unlisted codes, lab/pathology report, office/clinical notes for E/M and medical procedure unlisted codes). Claims without supporting documentation will be denied.

Provide an adequate definition/description of the nature, extent and need for the procedure (chunk 4).
Indicate relationship to other services (independent vs same surgical site/opening) and any extenuating circumstances (chunk 4).
Report time, effort, equipment, and number of times the service was provided (chunk 4).
Include additional clinical details: complexity of symptoms, final diagnosis, pertinent findings, diagnostic/therapeutic procedures, concurrent problems, follow-up (chunk 5).
Designate the portion of the report that identifies the test/procedure tied to the unlisted code (chunk 5).
Include the specific documentation per code range: E/M (99202-99499) = office/clinical note; Surgical (10004-69990) = operative/procedure report; Radiology (70010-79999) = imaging report; Lab/Path (80047-89398) = laboratory/pathology report; Medical procedures (90281-99607) = office notes/reports; Unclassified drug codes = NDC number, full description/name, strength and service units (see policy 10-008); Unlisted DME HCPCS = narrative on the claim (chunk 5).
Claims billed with unlisted procedure codes without supporting documentation will be denied (chunk 6).

Key Definitions

Definition of unlisted procedure codes

DefinitionUnlisted procedure codes are used to report services or procedures that are not otherwise specified by a specific CPT® or HCPCS code until a more specific code is established.

PurposeProvide a means of reporting and tracking procedures for which no specific CPT or HCPCS code exists; allowables are not established because unlisted codes describe many different procedures.

Claim formThis policy applies to professional services reported on a CMS-1500 claim or its electronic equivalent.

Reimbursement noteBecause unlisted codes describe diverse procedures, specific allowables are not established; reimbursement is determined case-by-case by Florida Blue.