†Centers for Medicare & Medicaid Services.
Medicare Claims Processing Manual, Chapter
26: Completing and Processing Form
CMS-1500 Data Set (Rev. 3637, 10-28-16).
Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/
clm104c26.pdf. Accessed June 30, 2017.
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TABLE 1. EXAMPLES OF CPT UNLISTED CODES AND COMPARISON CPT CODES
Procedure
performed
Unlisted CPT code reported
on claim form
Comparison CPT code
referenced in cover letter
Laparoscopic subtotal
gastrectomy with Roux-en-Y
43659, Unlisted laparoscopy procedure,
stomach
43633, Gastrectomy, partial, distal; with Roux-en-Y reconstruction
Laparoscopic gastrojejunostomy 43659, Unlisted laparoscopy procedure, stomach 43820, Gastrojejunostomy; without vagotomy
Laparoscopic internal hernia
repair
44238, Unlisted laparoscopy procedure,
intestine (except rectum)
44050, Reduction volvulus, intussusception,
internal hernia by laparotomy
Laparoscopic pylorotomy 43659, Unlisted laparoscopy procedure, stomach 43800, Pyloroplasty
Open appendicostomy 44799, Unlisted procedure, small intestine
44300, Placement, enterostomy or cecostomy,
tube open (eg, for feeding or decompression)
(separate procedure)
Phlebectomy, less than 10 stabs 37799, Unlisted procedure, vascular surgery 37765, Stab phlebectomy of varicose veins, 1 extremity, 10-20 stab incisions
Hemorrhoidectomy, external,
single column/group 46999, Unlisted procedure, anus 46255, Hemorrhoidectomy, internal and external, single column/group
fee for comparison CPT code
is $1,000, and therefore you
have set your fee for the unlisted
procedure at $1,500 because it
required 50 percent more time for
exposure and exploration.
•For Medicare patients, if the
unlisted procedure performed
is one that other surgeons may
perform in similar clinical
circumstances, it would be
helpful to share this information
with the surgical representative
on the Medicare Contractor
Advisory Committee (CAC).
This exchange provides the
opportunity to inform and
educate the Medicare Contractor
Medical Director (CMD) of the
new procedure so that future
cases may be reviewed and
processed more efficiently.
Eliciting the support of the
surgery CAC representative
provides the opportunity
to establish open lines of
communication with the CMD
to discuss coding and billing
issues as they arise, including
changes and updates in payment,
and other pertinent information
between the contractor and
medical community.
Keep in mind that the
percentage indicated in step 3 is
critically important, although
the payor will adjust up or
down from its fee schedule,
not the physician’s charge.
Coding examples
Table 1 on this page provides
examples of CPT unlisted codes
and comparison CPT codes
that should be reported for
procedures that do not have a
specific CPT or HCPCS code.
Conclusion
When reporting an unlisted
code to describe a procedure or
service, it is necessary to submit
supporting documentation
along with the claim to provide
an adequate description of the
nature, extent, and need for
the procedure and the time,
effort, and equipment necessary
to provide the service. For
more detailed information
about submitting an unlisted
code to Medicare, see Chapter
26 of the Medicare Claims
Processing Manual.† ♦
