Q: I have been told not to bill insurance carriers for unlisted modalities because they never pay for them. Is this true? If so, is there any way to appeal for payment?

A:Getting paid for unlisted procedures can be complicated. However, there are several things you can do to increase your chances of reimbursement.

First, call the insurance carrier and ask if they cover the procedure you are about to perform. If they consider it a noncovered service, make sure the patient is aware of this and then recommend the patient call the insurance carrier. Provide the patient with the name and number of the person you spoke with and tell them to ask the insurance carrier for their policy on unlisted and noncovered services.

Even if the insurance carrier does not pay for the unlisted procedure, it’s recommend you bill the insurance carrier anyway. This way, the insurance carrier will see you are providing the service, and the EOB will hopefully show a “patient responsibility” remark code.

Sometimes patients want their insurance carriers billed for unlisted and noncovered services so they know for sure they paid you properly. The “patient responsibility” EOB helps patients become educated on how their insurance carrier processes claims, and it makes it easier for you to get paid directly.

The insurance carrier will often deny the unlisted procedure due to “lack of medical necessity.” In this situation, get the insurance carrier to define “medical necessity.” Request a written definition and review it. You may be able to send in a “pre-authorization” letter in the future.

If you have clinical trials and research conducted by recognized bodies of physicians for the unlisted procedure, make sure you include that information in your letter. Describe the condition of the patient, how much he or she is suffering, and what the impact of this pain is on his or her life.

Include a lay-term description of the procedure in your letter so anybody who reads it can understand. Try to relate the procedure performed to an existing CPT code as support for reimbursement and explain how your procedure differs. This will show why you didn’t choose an existing code.

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