Unlisted Code Billing - JE Part A

When billing a service or procedure, select the CPT or HCPCS code that accurately identifies the service or procedure performed. If no such code exists, report the service or procedure using the appropriate unlisted procedure code (which often ends in 99). Noridian will not correctly code process an unlisted procedure when a valid code is available.

It is the responsibility of the provider to ensure all information required to process an unlisted procedure is included on the CMS-1450 form or the electronic media claim (EMC) when the claim is submitted. If required information is missing, or lacks a thorough description, the code will be deemed unprocessable and returned to provider (RTP).

An unlisted procedure code must have a concise description of the service or procedure rendered in Form locator 80 on the CMS-1450 claim form or electronic equivalent in the service line description. In the concise description of the procedure, it is helpful to include how the procedure was performed (e.g., laparoscopic, transnasal, infusion, with clip, type of graft, etc.), the body area treated and why it was performed.

Example: 85999 - Urine for Eosinophils

The electronic equivalent for form locator 80, 2300/2400 NTE, holds up to 80 characters for the concise statement. If the description does not fit in 2300/2400 NTE, providers who submit paper claims should include an attachment to describe the service or procedure. Also, an attachment can be submitted for EMC claims using the PWK submission method. See PWK article titled "Submitting Paperwork (PWK) Electronically."

Please do not submit a written request or contact the Noridian Provider Call Center to inquire if the description is appropriate for payment. We cannot determine if the comment is sufficient for payment without viewing the entire claim.

In addition to the provider requirement of a clear concise description of the service or procedure of unlisted codes, Noridian may ask for medical records to validate an unlisted procedure. Providers should not submit medical records unless an Additional Documentation Request (ADR) is issued.

Resource: CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 4