When a coding professional assigns an unlisted code, or a physician advises the use of an unlisted code, it does not mean that the coder is too lazy to work to find the appropriate code. Likewise, it does not mean that physician was too lazy to document appropriately. I heard both these comments recently. Neither is correct – and quite frankly, both are offensive. CPT guidance for unlisted codes in the Introduction pages in the front of the manual instructs that we are not to select a CPT code that merely approximates the service. If there is no specific code, then we are to use the appropriate unlisted code.

Because of the structure of Current Procedural Terminology and the process by which CPT codes are released, it takes time for a code to be assigned. Codes are developed and updated by the CPT Editorial Panel, an independent group of expert volunteers who represent various aspects of the health care industry. They are supported by the CPT Advisors, who represent various specialty societies. The CPT Editorial Panel meets three times a year to review applications for new codes or revisions to existing codes.

For most services, new CPT codes are assigned yearly with a January 1 effective date. For a service to be assigned a Category I CPT code, the service must be performed by many physicians or other qualified health care professionals across the US and with frequency consistent with the intended clinical use. The service must be consistent with current medical practice, and the clinical efficacy must be documented in literature. Category III codes for new technology can be assigned under less stringent requirements, but the process still takes some time for the code application to proceed through the CPT process.

In reviewing these criteria, there are various reasons for an unlisted code to be assigned. Perhaps this is a new service that has not yet received a code. Maybe the service is only performed in certain parts of the country. Maybe the service is rarely performed. Perhaps the specialty society has chosen not to move forward with a CPT code application for this service.

Most coding professionals will assign unlisted codes at some point in their careers. Understanding the proper use and knowing how to appeal will ensure compliant coding and reimbursement success.

Looking for more guidance on use of unlisted codes? Read Kim Huey’s article: “CPT Coding: The Appropriate Use of Unlisted CPT Codes” for examples, rules to know, and tips to help know when unlisted codes should be used.

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