CurrentmhnPolicy CC.PP.009

Unlisted Procedure Codes

Governs billing, documentation, and reimbursement for claims using unlisted CPT/HCPCS procedure codes for all product types and providers submitting to the Health Plan.

Policy Summary

Payermhn

PolicyUnlisted Procedure Codes

Policy CodePolicy CC.PP.009

Change TypeNo material change

Effective Date01/01/2013

Next Review Date

Key ActionIf the procedure is experimental, an authorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All product typesapplies to

Documentation requiredclaims with unlisted codes

Denial riskreimbursement policy

11/21/2024last review date

Reimbursement and Documentation Criteria

Unlisted code reimbursement and documentation criteria

Reimbursement and documentation expectations for claims with unlisted procedure codes.

Supporting documentation is required when filing a claim that includes unlisted procedure codes; claims submitted without supporting documentation are denied.

Unlisted procedure codes should not be used when a more descriptive procedure code representing the service provided is available; claims are denied if a more appropriate code is determined on review.

Supporting documentation must include: a clear description of the nature, extent, and need for the procedure or service; whether the procedure was independent from other services or performed at the same surgical site/opening as another procedure; any extenuating circumstances; an account of time, effort, and equipment required; and the number of times the procedure was performed. When submitting, designate and clearly mark the portion of the report that identifies the test or procedure associated with the unlisted code.

Required documentation types by CPT/HCPCS ranges: Surgical (10021-69990) = Operative/Procedure Report; Radiology/Imaging (70010-79999) = Imaging Report; Laboratory/Pathology (80047-89398) = Laboratory or Pathology Report; Medical (90281-99607) = Office Notes and Reports; Unlisted HCPCS = Operative/Procedure Report; Unclassified drugs = NDC number, full description/name, strength, and service units; Unlisted DME HCPCS = narrative on the claim and invoice/UPN if applicable.

Policy Summary

Payermhn

PolicyUnlisted Procedure Codes

Policy CodePolicy CC.PP.009

Change TypeNo material change

Effective Date01/01/2013

Next Review Date

Key ActionIf the procedure is experimental, an authorization is required.

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.

Unlisted Procedure Codes and Usage Guidance

Unlisted procedure codesmixed

unlisted CPT/HCPCS

Use when no specific CPT or HCPCS code exists for the service provided

Use of unlisted codes

Policy directiveDo not use unlisted codes when a more descriptive procedure code representing the service provided is available.

When to use unlisted codesReport the service with an appropriate unlisted procedure or service code only if no specific CPT/HCPCS code exists that accurately identifies the service performed.

Selection guidanceDo not select a CPT code that merely approximates the service performed; follow CPT 'Instructions for Use' to select the accurate procedure name.

ApplicabilityThis policy applies to claims containing procedure codes that are unlisted.

Documentation expectationWhen an unlisted code is used, adequate documentation must support the service and any modifying or extenuating circumstances should be added.

OpenPayer

Unlisted Procedure Codes

Reimbursement and Documentation Criteria

Unlisted Procedure Codes and Usage Guidance

Authorization and Provider Requirements

Key Definitions