How to Obtain Reimbursement for Unlisted Procedures

Pursue pre-authorization from payers to help ensure payment

Obtaining payment for unlisted procedures can be problematic. There are steps you can take, though, to increase your chances of reimbursement.

"It's not unheard of to get paid for unlisted procedures, but it's just not always easy," says Joanne Mehmert, CPC, CCS-P, in Kansas City, Mo. "The insurance company has its own definition of medical necessity."

Step 1: Get the payer to define "medical necessity." Request the definition by fax or email, review it and include it in your pre-authorization request letters.

Step 2: Try to obtain pre-authorization from the payer in a letter. If you have clinical trials that have been conducted by recognized bodies of physicians, make sure you include that information in your pre-authorization letter requesting approval for a pain management procedure for which you will be using an unlisted code. Your letter also should include any CPT codes that are similar in work and risk.

"Describe the condition of the patient -- how much they're suffering, what the impact of this pain is on that patient's life," Mehmert advises. Include a lay-term description of the procedure in your letter so that anybody who reads it can understand.

Try to relate the procedure performed to an existing CPT code as support for reimbursement. Explain how your procedure differs to show why you didn't choose an existing code, says Heather Corcoran, manager at CGH Billing Services in Louisville, Ky.

Finally, ensure the payer understands the anticipated cost of the care with and without that procedure. "The payers are looking for the money," Mehmert says. "You need to tell them how much the payer is going to save" if the procedure is done to minimize the risk of future, more expensive procedures.

Step 3: Study your payer's policies. Most medical policies that payers publish on their Web sites include disclaimers that every benefit plan defines what services are covered and what services are excluded, Mehmert says.

"One of the things you want to keep up with are those policies payers publish on their Web sites," she says. "Sometimes those policies can very much work in your favor." Of course, payment will vary widely by payer and by region.

Watch for employer plans: Payers often handle medical plans for employers. It is important to check the patient's benefit plan for payment information even if the payer Web site says that the procedure is not covered. "Sometimes you can be a little bit surprised because a specific plan or patient plan may cover the procedure," Mehmert says.

Ultimately, you should always adhere to the AMA official coding guidelines unless your contract with a payer stipulates otherwise. If you have had difficulty with a payer processing any unlisted procedure code, then you may address the issue with the payer rep who may, in writing, direct your provider that it is OK to report a CPT code not following the AMA CPT guidelines.