CurrentOscar HealthPolicy N/A

Unlisted and Unspecified Procedures

Defines Oscar Health's reimbursement and documentation requirements for services billed with unlisted or unspecified CPT and HCPCS codes, and applies to providers submitting such claims to Oscar Health.

Policy Summary

PayerOscar Health

PolicyUnlisted and Unspecified Procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateAug 1, 2025

Key ActionSubmit sufficient supporting documentation describing the specific service(s) rendered when billing with unlisted or unspecified CPT/HCPCS codes to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 rangescode ranges mapped to documentation

XXX99/XX999common unlisted suffixes

report oncesingle reporting rule

no extrano extra reimbursement

modifiers deniedmodifier denial rule

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Coverage Criteria for Unlisted/Unspecified Codes

Oscar will consider reimbursement for unlisted or unspecified CPT and HCPCS codes only when no appropriate specific code exists and when required supporting documentation and billing rules are met.

ALL of the following

ALL of the following
- Providers must select the CPT/HCPCS code that most accurately describes the service; use an unlisted code only as a last resort when no more appropriate specific code exists.
ALL of the following
- ALL of the following
  - A clear description of the nature, extent, and medical necessity of the procedure or service (including final diagnosis, complexity of symptoms, pertinent physical findings).
  - Whether the procedure was independent or performed at the same surgical site or through the same surgical opening as other services.
  - Extenuating circumstances that complicated the service or procedure.
  - Time, effort, and equipment necessary to provide the service.
  - The number of times the service was provided and relevant follow-up care.
- If a similar or like code exists, include that recommended comparable code to assist in review.
ALL of the following
- Surgical procedures (CPT 10021-69990): operative or procedure report required.
- Radiology/imaging procedures (CPT 70010-79999): imaging report required.
- Laboratory and pathology procedures (CPT 80047-89398): laboratory or pathology report required.
- Medical procedures (CPT 90281-99607): office notes and reports required.
- Unlisted HCPCS DME codes: physician prescription/order plus report and invoice required.
- Unclassified drug entries (NDC): NDC number with full description, name, and strength required.
ALL of the following
- Failure to provide requested supporting documentation that describes the specifics of the unlisted/unspecified code will result in denial of the service.
- Claims will be denied if a more appropriate procedure/service code is available.
- No additional reimbursement will be provided for special techniques or equipment submitted with an unlisted procedure code.
- When multiple procedures require the same unlisted CPT code, report that unlisted CPT code only once to identify the services provided (this exclusion does not apply to unlisted HCPCS codes such as DME or unlisted drugs).
- Unlisted procedure codes appended with a modifier will be denied, except unlisted DME/orthotics/prosthetics codes which require an appropriate DME modifier per the Durable Medical Equipment policy to be considered for reimbursement.

ALL of the following

When submitting documentation, clearly designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code.

Unlisted/Unspecified Codes and Required Documentation

Unlisted procedure code groups and required documentationCPTCovered

10021-69990	Unlisted surgical procedure codes — Operative or procedure report required
70010-79999	Unlisted radiology/imaging procedure codes — Imaging report required
80047-89398	Unlisted laboratory and pathology procedure codes — Laboratory or pathology report required
90281-99607	Unlisted medical procedure codes — Office notes and reports required

Unlisted HCPCS/DME and Unclassified drug codesHCPCS | NDCCovered

Unlisted HCPCS (DME)	Unlisted HCPCS DME codes — Physician prescription/order; report and invoice required
Unclassified drug (NDC)	Unclassified drug codes — NDC number with full description/name and strength required

Documentation Submission and Billing Actions

Denial Risk

Documentation submission and denial risk

Providers must submit supporting documentation when billing unlisted or unspecified CPT/HCPCS codes. Oscar may request operative reports, imaging reports, lab/pathology reports, office notes, NDC details, prescriptions/orders, and invoices as applicable. Failure to supply requested documentation that clearly describes the specific service(s) rendered and why an unlisted/unspecified code was used will result in denial of reimbursement. Claims using an unlisted or unspecified code may also be denied if a more appropriate, specific procedure/service code is available.

Include a clear description of the nature, extent, and medical necessity of the service.
Indicate whether the procedure was independent or part of other services at the same site/opening.
Document extenuating circumstances, time, effort, and equipment used, and the number of times the service was provided.
Attach the specific report type by unlisted code range: surgical (operative/procedure report), radiology (imaging report), laboratory/pathology (lab/path report), medical (office notes/reports).
For unclassified drugs: provide NDC number, full drug name, and strength. For unlisted DME: provide physician prescription/order plus invoice.
If a similar or like code exists, identify it and explain why the unlisted code was used to assist review.

Definitions: Unlisted and Unspecified Codes

Unlisted / Unspecified Code descriptors and suffixes

Descriptors found in CPT/HCPCS unlisted codesTerms include 'unlisted', 'unspecified', 'unclassified', 'NOS/NOC', 'NEC', or 'miscellaneous' as stated in the code description.

Common code suffixesThese codes usually end in XXX99 or XX999.

Typical location in codebooksOften located at the ends of code sections, though sometimes intermixed within the same section.

PurposeUsed when an item, service, or procedure cannot be accurately described by an existing specific CPT or HCPCS code.

Examples of wording in code descriptionsCode descriptions will explicitly state phrases such as 'unlisted', 'unspecified', 'not otherwise specified (NOS)', 'not otherwise classified (NOC)', or 'not elsewhere classified (NEC)'.

OpenPayer

Unlisted and Unspecified Procedures

Coverage Criteria for Unlisted and Unspecified Codes

Unlisted/Unspecified Codes and Required Documentation

Documentation Submission and Billing Actions

Definitions: Unlisted and Unspecified Codes