CurrentHighmark Blue Cross Blue Shield WnyPolicy G-06004

Unlisted or Miscellaneous Codes reimbursement

Governs reimbursement for unlisted or miscellaneous CPT/HCPCS codes for MMC, HARP, Child Health Plus, and Essential Plan members and outlines required documentation for claim review.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyUnlisted or Miscellaneous Codes reimbursement

Policy CodePolicy G-06004

Change TypeNo material changes

Effective DateNov 4, 2024

Next Review DateN/A

Key ActionUse unlisted/misc codes only when no established code exists and submit supporting documentation (description, notes, invoice, NDC) for individual claim review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MMC/HARP/CHPlus/EssentialPrograms covered

Individual reviewReimbursement basis

Description, notes, invoice, NDCDocs required

Policy review historyHistory present

Unlisted / Miscellaneous Code Coverage Criteria

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Unlisted/Miscellaneous Code Coverage Criteria

Covered when ALL of the following conditions are met:

ALL of the following

Unlisted or miscellaneous codes are used only when an established code does not exist to describe the diagnosis, service, procedure, or item rendered.
Claims include required documentation for review: a written description (office notes or operative report), an invoice with item descriptions, and the National Drug Code (NDC) when the unlisted code is for a drug.
Providers use industry-standard CPT, HCPCS, and/or revenue codes and fully support billed services in the medical record; appropriate coding/billing guidelines must be followed.
AND reimbursement is determined only when one of the following applies
- Reimbursement is determined on an individual claim review of the submitted documentation.
- Services meet applicable authorization and medical necessity guidelines appropriate to the procedure and diagnosis.
- The request is not precluded or superseded by provider, state, federal, or CMS contracts or requirements; if such mandates exist, those requirements govern reimbursement.

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Coding and Code Listings

Unlisted/Miscellaneous codesmixed

unlisted CPT/HCPCS

Codes used when no specific CPT or Level II HCPCS code exists to describe the service, procedure, item or drug

Coding standard requirement

Required code systemsUse industry-standard CPT, HCPCS, and revenue codes on all claim submissions.

Medical record supportBilled services and procedures must be fully supported in the medical record and/or office notes.

Billing guidanceServices should be billed with Current Procedure Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and/or revenue codes.

Consequences of noncomplianceIf coding/billing guidelines or reimbursement policies are not followed, Highmark BCBS may reject/deny the claim, recover/recoup payment, or adjust reimbursement.

Prior Authorization and Documentation Expectations

Documentation Required

Prior authorization and documentation expectations for unlisted/misc codes

Use unlisted or miscellaneous codes only when no established code exists to describe the diagnosis, service, procedure, or item rendered. When submitting a claim with an unlisted or miscellaneous code, include a written description (office notes or operative report), an invoice with written descriptions of items and supplies, and the corresponding National Drug Code (NDC) for unlisted drug codes so the claim can be reviewed for reimbursement; reimbursement is determined on an individual claim basis and services must meet authorization and medical necessity requirements. Providers must also follow industry-standard CPT, HCPCS, and/or revenue coding and fully support billed services in the medical record; failure to follow billing/submission guidelines may result in claim denial, recoupment, or adjustment.

Use unlisted/misc codes only when no established code exists to describe the service.
Include written description (office or operative notes) describing the procedure or service performed.
Include an invoice with written description of items and supplies.
Provide the corresponding NDC for unlisted drug codes when applicable.
Ensure services meet authorization and medical necessity guidelines and are fully supported in the medical record.

Definitions

Miscellaneous (definition)

DefinitionCodes submitted by a supplier for an item or service for which there is no existing code that adequately describes the item or service being billed.

When to useUsed when no existing code adequately describes the item or service being billed.

Relation to reviewMiscellaneous submissions require supporting documentation for individual claim review as outlined in the policy.

Unlisted (definition)

DefinitionAn unlisted HCPCS code represents an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code. CPT unlisted codes typically have descriptors starting with 'Unlisted' and commonly end in 99.

Location in CPTThe CPT code book places unlisted service/procedure codes at the end of a section or subsection and summarizes them in chapter Guidelines.

Use caseUse an unlisted code when no specific CPT or Level II HCPCS code exists to describe the service, procedure, item, or drug.