“All good things must come to an end,” and I’m afraid my authorship of this column is another one of those things. After more than 20 years writing for Ophthalmology Management’s readers, I will be handing this column off to another veteran of the coding and reimbursement struggle — my colleague Brandy Sperry. I have enjoyed your questions and know that I am leaving you in good hands for the questions to come.

Now for my final column …

Q. When are “unlisted” or “miscellaneous” codes used?

A. These are procedures that are not specifically described in Current Procedural Terminology (CPT); an unlisted procedure code must be used on claims to describe the procedure. The CPT codebook instructs, “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.¹ Here’s an example from the August 2022 edition of CPT Assistant.²

“Question: Is code 65820 the appropriate code to report when a surgeon uses a tool or device to create one or more punctures in the trabecular meshwork to inject small amounts of viscoelastic material into Schlemm’s canal? 

Answer: No, the procedure described by code 65820 requires the incision or excision of the trabecular meshwork, utilizing a blade or other tool, for at least several clock hours to circumferentially cut, unroof or more of the diseased trabecular meshwork. When the surgeon injects viscoelastic material into a limited portion of the canal via one to three opening(s), report code 66999, Unlisted procedure, anterior segment of eye.”

Likewise, CMS policy states, “A physician shall not report a CPT code for a specific procedure if it does not accurately describe the service performed. It is inappropriate to report the best fit HCPCS/CPT code unless it accurately describes the service performed, and all components of the HCPCS/CPT code were performed.”³ This policy mirrors the instructions in CPT as described above.

Q. What does Medicare require?

A. Physicians can be reimbursed for unlisted procedure codes. Also, HOPDs are eligible for reimbursement within the Outpatient Prospective Payment System (OPPS). Those providers submit claims with supporting documentation, and the Medicare Administrative Contractor (MAC) makes individual payment determinations. Unlisted CPT codes require additional documentation to be covered.⁴ This includes:

• An amplified operative report that contains indications, description of the procedure and supplies used, identified risk factors, duration, intensity and comparable procedures.
• A concise description of the procedure in 80 characters or less in Item 19 of the CMS-1500 claim form.⁵
• A rationale for your charge based on the work involved, skill required, supply costs, physician time and methodical comparison to similar services.

According to Federal Regulations, ASCs are ineligible for reimbursement of unlisted procedures.⁶ In the 2017 final OPPS payment rule, CMS stated that “all unlisted codes are noncovered in the ASC because we are unable to determine (due to the nondescript nature of unlisted procedure codes) if a procedure that would be reported with an unlisted code would not be expected to pose a significant risk to beneficiary safety when performed in an ASC, and would not be expected to require active medical monitoring and care of the beneficiary at midnight following the procedure.”⁷

As a result, ASCs could not collect money from the beneficiary for these noncovered services.

In March 2023, CMS changed the Medicare Claims Processing Manual. It now says, “Covered ASC services are those surgical procedures that are identified by CMS on a listing that is updated at least annually. Some surgical procedures are covered by Medicare but are not on the list of ASC covered surgical procedures. For surgical procedures that are performed but not covered in ASCs, the related professional services may be billed by the rendering provider as Part B services, and the beneficiary is liable for the facility charges, which are non-covered by Medicare.”⁸

It goes on to say, “Facility services for surgical procedures are excluded from the ASC list. ASC bills beneficiaries for facility charges associated with the noncovered procedure.”

Q. What does an ASC need to do?

A. While payment for non-covered services is the beneficiary’s responsibility, Medicare law contains a provision that waives liability if the beneficiary is not likely to know, and did not have a reason to know, that the services would not be covered.⁹ For ordinary Medicare (Part B), the beneficiary must be informed in writing of the noncovered items and services, the expected charge, and the reason for noncoverage then given the opportunity to decide. An ABN is the form used for this purpose. The ABN form is the only approved financial waiver for Part B Medicare.¹⁰ 

Medicare Advantage Organizations (MAOs), or Part C Medicare, have been instructed by CMS not to use an ABN. In a forceful memo from May 2014, CMS reminded MAOs that they are obliged to make pre-service determinations of benefits at the request of the physician or the patient. Without notice of noncoverage prior to a non-covered service, the Medicare beneficiary is not financially responsible. A refund may be due if the beneficiary makes a payment without following this process.¹¹ Unfortunately, there is no single form or process for all MAOs; each one does this a little differently. Check with the MAO plan for instructions.

For non-Medicare beneficiaries, there is more latitude. A Notice of Exclusion from Health Plan Benefits is a customizable form that identifies items and services that are not covered under the beneficiary’s plan.¹² This is a useful tool to clearly inform beneficiaries about coverage policies and financial responsibility to avoid misunderstandings later.

Q. What if we do this wrong?

A. In cases where a mistaken Medicare claim is filed using a CPT code that is “close enough” and an unlisted CPT code should have been used, then the following problems may result:

• The coverage of the procedure is in question; it might not be covered. The MAC will need to make a determination.
• The Medicare reimbursement for the surgeon is in error. Medicare needs to reprocess the claim with an unlisted procedure code and reassess the payment amount.
• The Medicare reimbursement for the ASC facility fee is in error. Medicare should not have paid; the financial responsibility belongs to the patient. A refund is due. 

Under the provisions of the compliance plans for the ASC and clinical practice, all personnel need to be educated on unlisted procedure codes to avoid future errors.  OM

References

1. 1. 2024 CPT Professional Edition
   2. CPT Assistant, August 2022
   3. NCCI Policy Manual for Medicare Services, Unlisted Procedure Codes, I-28.  https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf 
   4. Bulletin of the American College of Surgeons. Unlisted Procedures: Strategies for Successful Reimbursement.  August 2, 2017.  https://bulletin.facs.org/2017/08/unlisted-procedures-strategies-for-successful-reimbursement/ 
   5. CMS MCPM, Chapter 26, §10.4 Item 24D https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c26pdf.pdf
   6. 42 CFR 416.166(c)(7) Covered surgical procedures. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-416  
   7. CMS-1656-FC, Federal Register Vol 81 No 219 p 79743 https://www.govinfo.gov/content/pkg/FR-2016-11-14/pdf/2016-26515.pdf
   8. Medicare Claims Processing Manual, Chapter 14, §10.2 https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c14.pdf
   9. Limitation on liability of beneficiary where Medicare claims are disallowed SSA Section 1879. https://www.ssa.gov/OP_Home/ssact/title/1879.htm.
   10. CMS.gov. FFS ABN. April 2023. https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn.
   11. gov. CMS Memo to MA plans. Improper Use of Advance Notices of Non-Coverage. May 2014 https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/improper%20abn%20use%2005%2005%2014_156.pdf 
   12. Corcoran Consulting Group Forms https://www.corcoranccg.com/products/forms/nehb-notice-of-exclusion-from-healthplan-benefits 

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.