You can get paid for unlisted procedures, but the road is not always easy, mor eso in pain management and anesthesia practice. However, there are ways you can boost your chances of reimbursement.
You should make an effort to obtain pre-authorization from the payer in a letter. If you have clinical trials that have been conducted by recognized bodies of physicians, see to it that you include that information in your pre-authorization letter requesting approval for a pain management procedure for which you’ll be using an unlisted code.
The letter should also include any current CPT codes that are similar in work and risk.
Study payer’s policies for tips. Most medical policies that payers publish on their websites include disclaimers that every benefit plan defines what services are covered and what services are excluded. One of the things you want to keep up with are those policies payers publish on their websites. It may so happen that sometimes those policies can very much work to your advantage.
Keep a watch on employer plans. Payers often handle medical plans for employers. It is essential to check the patient’s benefit plan for payment information even if the payer website says that the procedure isn’t covered. Be prepared for a bit of a surprise as well because sometimes a specific plan may cover the procedure.
But in the end you should stick to the AMA official coding guidelines unless your contract with a payer stipulates otherwise. If you have any difficulty with a payer processing any unlisted procedure code, then you may take in hand the issue with the payer rep who may direct your provider that it’s all right to report a CPT code breaking away from the AMA CPT guidelines.
To get free CPT code information, there are various one-stop websites that offer free trials. Once you’re sure the website meets your purpose, you can get yourself registered there.