42999
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A specific written report describing the service, item or supply provided when an unlisted code is billed.
- An invoice for unlisted or miscellaneous items or supplies, when applicable, to determine coverage.
- Documentation must state whether the service was provided independent from other services and whether it was performed at the same site or through the same surgical opening.
- Medical records demonstrating medical necessity, including documentation that the service is required to diagnose or treat an illness/injury/disease or its symptoms, is in accordance with generally accepted standards of medical practice, and is clinically appropriate in type, frequency, extent, site and duration.
Key Coverage Criteria
- Use of an unlisted CPT or HCPCS code when there is an absence of an available CPT or HCPCS procedure code that accurately describes the service.
- Procedure that is entirely new, unproven, or potentially investigational (when an appropriate unlisted code is used and criteria are met).
- An established procedure performed by a different method or approach (when an appropriate unlisted code is used and criteria are met).
- An established procedure using a different device than described by standard available codes (when an appropriate unlisted code is used and criteria are met).
- A procedure performed at a different anatomical location than described in standard available codes (when an appropriate unlisted code is used and criteria are met).
- Medical necessity for the unlisted code established by supporting documentation, including a specific written report describing the service and, when applicable, an invoice for unlisted/miscellaneous items or supplies.
1 Active Policy
CIGNA-0583 — Unlisted Procedure Codes - (0583)
Related Codes
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