CurrentSelectHealthPolicy 08

Unlisted/Unspecified CPT and HCPCS procedure codes

Defines SelectHealth's reimbursement, documentation, and preauthorization requirements for unlisted or unspecified CPT/HCPCS procedure and drug codes across Commercial, Medicare (CMS), and Medicaid plans.

Policy Summary

PayerSelectHealth

PolicyUnlisted/Unspecified CPT and HCPCS procedure codes

Policy CodePolicy 08

Change TypeNo material change

Effective DateDec 30, 2023

Next Review Date

Key ActionObtain required prior authorization before rendering services for unlisted codes on Medicare and Medicaid plans.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior auth reqMedicare & Medicaid requirement

Comparable feePricing approach

Supporting docsDocumentation requirement

No increaseNo addl payment

Coverage and Payment Rules for Unlisted Codes

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 may be reported only when no specific CPT/HCPCS code adequately describes the item, procedure, or service.

Providers must submit complete descriptions and supporting documentation (operative notes, imaging, invoices, NDCs for drugs, comparable CPT/HCPCS code and RVU or suggested pricing) to support reimbursement determinations.

Claims with unlisted codes are reviewed for a more appropriate listed code; if a more appropriate CPT/HCPCS code adequately describes the service, the claim may be denied.

Special techniques or equipment, including robotic or computer-assisted navigation, will not increase procedure reimbursement when billed with an unlisted procedure code.

Payment for drugs and biologics billed with an unlisted procedure code will be determined by the plan rather than strictly by units billed; include NDC, dosage, NDC units, and qualifier when submitting.

Pricing when adequate data exists

SelectHealth may establish permanent fee schedules when adequate data exists (e.g., local, regional, or national claims experience).
SelectHealth may derive fees using comparable CPT/HCPCS codes or RVU calculations when an equitable fee can be established based on similarity to a listed procedure.

Plan variations

SelectHealth Commercial allows reimbursement when supported by documentation.
SelectHealth Medicare and SelectHealth Community Care follow the Commercial policy but require prior authorization for all unlisted codes.

Code Identifiers and Coding Rules

Unlisted procedure code identifiersCPT

XXX99 / XXXX9

Placeholder format noted for unlisted CPT/HCPCS procedure codes located at ends of sections

When an equivalent listed code exists — denial and equitable fee rule

Policy ruleIf a more appropriate CPT/HCPCS code adequately describes the service, the claim may be denied and an equitable fee may be established using the comparable code.

Basis for equitable feeEquitable fee may be derived when the unlisted procedure is so similar to a listed procedure that a comparable CPT/HCPCS code and fee exist (example: unlisted laparoscopic vs equivalent open procedure).

Pricing sourcesSelectHealth may use RVU calculations, comparable CPT/HCPCS fees, or local/regional/national claims experience to determine an equitable fee when adequate data exists.

Preauthorization, Documentation, and Billing Procedures

Prior Authorization

Obtain prior authorization for unlisted codes

Providers must determine whether an item, procedure, or service billed with an unlisted code requires preauthorization and obtain that authorization prior to rendering services to the SelectHealth member. All unlisted codes require prior authorization on SelectHealth Medicare and SelectHealth Community Care (Medicaid) plans.

Providers are responsible for obtaining prior authorization before services are rendered.
SelectHealth Medicare and SelectHealth Community Care add the requirement that all unlisted codes require prior authorization.

Denial Risk

Risk of delayed or denied claims if preauthorization/documentation not provided

Failure to submit required preauthorization(s) and supporting documentation within the required timeframes may result in claim delays or denials. Documentation must be sufficient and clearly marked to support the unlisted code billing.

Submit signed medical records (operative/office notes, imaging, labs, pathology) and complete descriptions of the item/procedure/service.
For unlisted drugs include NDC, dosage, NDC units, and NDC qualifier; for DMEPOS include manufacturer invoice with product number and description.
Provide comparable CPT/HCPCS code(s), comparable RVU, or suggested pricing to support reimbursement determinations.

Terminology for Unlisted Procedure Codes

Unlisted procedure code descriptors

Common descriptorsNot Elsewhere Classified (NEC); Not Otherwise Classified (NOC); Not Elsewhere Specified (NES); Not Otherwise Specified (NOS).

Additional termsNot Listed; Non-Specified; Unclassified; Unlisted; Unspecified.

Usage guidanceThese terms in CPT/HCPCS code descriptions indicate the code is unlisted/unspecified and may require supporting documentation for reimbursement.