Effective Date: April 1, 2021
This policy provides guidelines for appropriately billing of unlisted and unspecified procedure codes.
- NJ FamilyCare/Medicaid Plan
- Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)
- Unlisted Code: Represents an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code.
According to coding guidelines, when billing a service or procedure, you must select the CPT or HCPCS code that accurately identifies the service or procedure performed. Unlisted codes should be reported only if no other specific codes adequately describes the procedure or service.
Because unlisted codes do not describe a specific procedure or service, documentation is always required for reimbursement. Documentation when reporting an unlisted code should include the following as applicable:
- A detailed and clear description of what the unlisted code is being used for
- Any extenuating circumstances which may have complicated the service or procedure
- A comparable pay as code
- Procedure or operative report
- Invoice for the unlisted DME codes
- National Drug Code (NDC) number with full description/name and strength of the drug and dosage when using un classified drug codes
Note: When submitting supporting documentation, identify the portion of the report (such as underlining or highlighting the entry) that identifies the test or procedure associated with the unlisted procedure code.
Multiple units will not be allowed for any unlisted code. Only one (1) unit may be submitted for unlisted codes. If more than one (1) unit is billed, the additional units will deny.
Horizon NJ Health will review submitted documentation for appropriateness of the unlisted code and for a reasonable reimbursement allowance.
Horizon NJ Health will not consider for reimbursement claims submitted with unlisted or unspecified codes without appropriate supporting documentation/medical records.
Horizon NJ Health will not consider for reimbursement claims submitted with an unlisted or unspecified code when records support a more appropriate procedure or service code.
Horizon NJ Health will not consider for reimbursement claims submitted with an unlisted or unspecified codes when the service is determined inclusive to other serviced billed for the same date of service.
Horizon NJ Health, when considering for reimbursement, shall only allow one (1) unit of an unlisted code. All units above one (1) unit will not be considered for reimbursement.
Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:
- Benefit Limitations
- The terms of any applicable provider participation agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Medical necessity; and
- Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.
Medicare Claims Processing Manual, Chapter 26, Completing and Processing Form CMS-1500 Data Set
American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services