Why unlisted CPT codes can cause trouble when filing claims
Published by
Christine Murphy
on
Recently we published an article about the anatomy of a CPT code. In it, we explained how these digits keep everything clear and consistent for payers and providers. But what about unlisted codes? Some payers have stopped accepting them altogether. Here's why.
Imagine you’re shopping for soup and, at the store you’re in, the soup cans have no labels. It’s a whole aisle of identical, anonymous silver cans – all with different price tags. So you ask the clerk what’s in each can.
He tells you, “These soups are so unusual that we don’t have labels for them. To find out what’s in a can, you have to buy it.”
“I have to know what’s inside before I decide it’s worth the price you’re asking,” you exclaim.
“Buy it! Then you can open it to find out what you bought!” the clerk says cheerfully.
I’m guessing most people would leave this store without any soup.
Health insurance payers face a similar dilemma when managing claims for “unlisted services.” Providers use unlisted /NOC/ NOS codes to report services that cannot be articulated by any other code in the CPT / HCPCS lexicon.
Much like a consumer who can’t tell whether an unlabeled can contains caviar or baked beans, payers confronted with unlisted codes can’t assess the value of the service without more information. Sometimes we ask the provider for medical records, which creates a bottleneck in the claims reimbursement process. This, in turn, can create administrative overhead, which ultimately drives higher premiums. These issues have led some payers to stop accepting unlisted codes altogether.
However, there are times when using an unlisted code is entirely appropriate, so insurance payers should work with providers to find an effective system for managing unlisted codes. For example, providers in the AllWays Health Partners network can complete this form to detail the service(s) they plan to report using an unlisted code. This allows us to price the service appropriately to avoid unnecessary claims denial and to keep administrative costs down.