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Unlisted procedure code

Sandeep Posted Thu 23rd of January, 2020 08:29:20 AM
My client is performing many unlisted procedures related to GI endoscopy. Many times they perform usual endoscopy portion( biopsy, control of bleeding). In addition they perform a procedure which can be coded by unlisted code. My questions are 1) Should we report normal endoscopy portion with available CPT code( 45380 etc or diagnostic CPT e.g 45378 etc if colonoscopy was normal) 2) For the unlisted portion, if complete colonoscopy has been performed and unlisted procedure has taken place only in rectum. should we report unlisted procedure code for rectum or unlisted procedure code for colon? 3) If the colonoscopy is incomplete how coding will be for colonoscopy part and for unlisted part?
SuperCoder Answered Fri 24th of January, 2020 06:01:31 AM

Hi,

 

Thank you for your Question.

 

According to the Current Procedural Terminology Instructions for use of the CPT, 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. Any service or procedure must be adequately documented in the medical record.

 

  1. Should we report normal endoscopy portion with available CPT code (45380 etc or diagnostic CPT e.g 45378 etc if colonoscopy was normal)- When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378. If a therapeutic colonoscopy was performed then use CPT code 45380.
  2. For the unlisted portion, if complete colonoscopy has been performed and unlisted procedure has taken place only in rectum. should we report unlisted procedure code for rectum or unlisted procedure code for colon? If more specific code exists from colon then report that specific code and for another anatomical location if specific code doesn’t exist, then report with unlisted code from that specific section.

 

  1. If the colonoscopy is incomplete how coding will be for colonoscopy part and for an unlisted part?  CPT®, in contrast to CMS rules, instructs, “For an incomplete colonoscopy, with full preparation for a colonoscopy, use a colonoscopy code with the modifier 52 [Reduced services] and provide documentation.” Some non-Medicare payers may follow CMS guidelines for an incomplete colonoscopy (modifier 53), while others may adhere to CPT® instructions (modifier 52). Check with specific payers for their respective recommendations.

Note: When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation along with the claim to provide an adequate description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service.

For more information kindly go through the undermentioned link.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1657CP.pdf

 

Hope that Helps!

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