Billing and Reimbursement for Unlisted CPT Codes in Urology

When assigning CPT codes for Urology procedures, there are times when there is not a code that accurately describes the service provided. In these instances, the procedure should be reported with the appropriate unlisted CPT code.  

One of the main reasons for using an unlisted procedure is because of the technique. More and more providers are using laparoscopic techniques with robotics to perform what have been traditionally open procedures. Since the CPT Code specifies “any open technique,” a different code must be used, and it’s usually an unlisted one. For example: 

CPT 51596 is a cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder. 

If this same procedure is performed laparoscopically, this code cannot be used and 51999 should be billed, with the comparable code of 51596.

Reporting an unlisted procedure requires additional work prior to submitting a claim for payment and after claim submission to ensure correct claim processing and reimbursement. Below are key steps to follow to help facilitate these processes.

• If possible, contact the payer prior to performing the procedure to obtain prior authorization.
• The service must be accurately and appropriately documented in the medical record. This includes a description of what the provider did and support for the medical necessity of the service.
• The unlisted code reported must be from the correct anatomic CPT list. For example, an unlisted procedure performed on the bladder should be reported with CPT 51999.
• Refer to a comparable procedure CPT code when setting a fee for the unlisted code. Set the unlisted procedure fee higher or lower based on whether the performed procedure was more or less difficult than the comparable one.
• A copy of the operative report should be submitted with the claim. Individual payers may have processes set up for submitting claims containing unlisted CPT codes. You can also put a description of the procedure in Item 19 on the CMS-1500 claim form.
• Be proactive in following up with payers. You may need to submit additional information or appeal an initial claim denial.

Although billing for unlisted procedure services can require more work, checking payer requirements and submitting the procedure detail will aid in a quicker turnaround time for claim processing and payment.