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Unlisted/Non-specific HCPCS/CPT CodesPolicy Number: PG0097Last Review: 05/03/2021ADVANTAGE ELITE HMOINDIVIDUAL MARKETPLACE PROMEDICA MEDICAREPLAN PPOGUIDELINESThis policy does not certify benefits or authorization of benefits, which is designated by each individualpolicyholder contract. Paramount applies coding edits to all medical claims through coding logic softwareto evaluate the accuracy and adherence to accepted national standards. This guideline is solely forexplaining correct procedure reporting and does not imply coverage and reimbursement.SCOPEX ProfessionalX FacilityDESCRIPTIONHealthcare Common Procedure Coding System (HCPCS) are billing codes developed by the Centers of Medicareand Medicaid Services (CMS). They are assigned to every task and service a medical practitioner may provide to apatient including medical, surgical and diagnostic services.Current Procedural Terminology (CPT) are billing codes developed by the American Medical Association (AMA)that describes the range of services that can be billed for by a physician, hospital, or outpatient facility that providesmedical services. According to the Current Procedural Terminology Instructions for use of the CPT Codebook,select the name of the procedure or service that accurately identifies the service performed. Do not select a codethat merely approximates the service provided. If no such specific code exists, then report the service using theappropriate unlisted procedure or service code. Unlisted procedure codes are not to be utilized if an appropriateCategory III code exists.Unlisted procedure codes are to be used when no other HCPCS/CPT code exists to reflect the procedure orservice the provider wants to submit for reimbursement. It may be a variation of a current service provided, butperformed in a different surgical technique, or it may be a whole different type of treatment method that could bedeemed experimental. It can also be defined as a component of other services performed (i.e. provider fails todocument it as a separate and distinct service), and it may be denied if it is not supported within thedocumentation. Any service or procedure should be adequately documented in the medical record.Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code isestablished. As new and advanced approaches and techniques are under development, the unlisted codes areused for auditing purposes until these procedures become accepted in medical practice and are routinelyperformed by providers. Specific fee allowances and/or relative value units (RVUs) cannot be established forunlisted services or items. Fees for unlisted codes are assigned once the documentation has been reviewed.Unlisted codes are identified in part by one of the following terms in the HCPCS description: Not Otherwise Classified Unlisted Not Listed Unspecified Unclassified Not Otherwise Specified Non-specified Not Elsewhere Specified NEC NOSPG0097 – 05/03/2021

POLICYUnlisted or not otherwise classified (NOC) and miscellaneous codes do not provide clearinformation about the service or item being billed. Paramount requires that additional informationaccompany claims for any unlisted and miscellaneous service or item being billed. Services mustmeet benefit coverage along with medical necessity guidelines appropriate to theprocedure/service. Some procedures/services that are billed with an unlisted code may requireprior authorization for coverage determination and benefit eligibility.Examples of procedures/services requiring prior authorization include (this list may not be allinclusive): Experimental/investigational New technology Cosmetic Plastic and reconstructiveA provider must refer to the Paramount prior authorization list and specific medical policy inreference to specific procedures/services billed with an unlisted code (this list may not be allinclusive): PG0035 Outpatient Advanced Imaging Authorization PG0041 Genetic Testing PG0114 Enteral and Parenteral Nutrition PG0135 Speech Generating Devices PG0163 Bariatric Services PG0194 Avise PG PG0203 Skin Substitutes PG0284 Power Mobility DevicesReimbursement is based on review of the unlisted code(s) on an individual claim basis. If anunlisted procedure code does not require prior authorization, documentation submitted with theclaim is required to justify the use and validity of the unlisted code and to describe theprocedure/service rendered to determine the nature and scope of the procedure and to determinewhether or not the procedure is covered, was medically necessary, and if separate service iswarranted or is a bundled service.Product code S5199 is non-covered.COVERAGE CRITERIAHMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, AdvantageParamount reimburses medically necessary unlisted procedures and services. Paramount expects that the use ofunlisted codes is limited to situations where there is truly no listed code or combination of codes that adequatelydescribes the service provided. Claims submitted with an unlisted code will be denied if determined an appropriateprocedure or service code is available.Claims with unlisted codes must be submitted with supporting documentation. The type of information required willvary depending on the type of service or item being billed. Supporting documentation should include the following: A clear description of the service, device or procedure provided, i.e.o Diagnostic testing should include: a diagnosis, the diagnostic report, the test performed and results of the testo Surgery procedures should include: a description of the nature, extent and need for the procedure,PG0097 – 05/03/2021

Operative/procedure/office notes Supporting documentation that identifies the unlisted/NOC codes pertinent to theitem, service or procedure performed; designation must be underlined (nothighlighted) an indication why an established standard coded CPT procedure is not appropriate provide a reasonably comparable CPT/HCPCS service code(s), value in comparable RVUand/or percentage of a reasonably comparable CPT/HCPCS that reflects the workperformed.o Laboratory and Pathology procedures should include: the laboratory or pathology test performed and the laboratory or pathology reporto DME items should include: the name of the item, a description, the manufacturer, product number and a copy of the invoiceo Miscellaneous Drugs should include: drug name the NDC number of the drug and dosage informationRequired information must be legible and clearly markedReference to whether the service, device or procedure was provided separately from any other service,device or procedure renderedInformation to establish medical necessity for the service, device or procedureHow the charges were derived for the service, device or procedure. Invoices are required.Claims submitted with an unlisted procedure code will be denied if determined that a more appropriate procedureor service code that most closely approximates the service performed is available.No additional reimbursement is provided for special techniques/equipment submitted with an unlisted code.Claims submitted with unlisted procedure codes and without supporting documentation may be denied for chartnotes or may be denied.Reporting an unlisted procedure code for the use of robotic or computer assisted surgical navigation does notincrease the reimbursement for performing the serviceDo not append modifiers to unlisted product or service codes. (Exception: Unlisted codes for DME, orthotics andprosthetics require appropriate NU, RR or MS modifier.)When performing two or more procedures that require the use of the same unlisted CPT code, the unlisted codeshould only be reported once to identify the services provided (excludes unlisted HCPCS codes; for example,DME/unlisted drugs).Unlisted or not otherwise classified (NOC) and miscellaneous codes Unit Value should always be one (1) (excludesunlisted DME Drug codes).Claims submitted with unlisted procedure codes for experimental/investigational services will be denied (Exception:a prior authorization was obtained for the specific service).CODING/BILLING INFORMATIONThe appearance of a code in this section does not necessarily indicate coverage. Codes that are covered mayhave selection criteria that must be met. Payment for supplies may be included in payment for other servicesrendered.PG0097 – 05/03/2021

CPT/HCPCS CODE The following CPT/HCPCS procedure codes require supporting documentation (this listmay not be 447994489944979Unlisted anesthesia procedure(s)Unlisted procedure, excision pressure ulcerUnlisted procedure, skin, mucous membrane and subcutaneous tissueUnlisted procedure, breastUnlisted procedure, musculoskeletal system, generalUnlisted maxillofacial prosthetic procedureUnlisted craniofacial and maxillofacial procedureUnlisted musculoskeletal procedure, headUnlisted procedure, neck or thoraxUnlisted procedure, spineUnlisted procedure, abdomen, musculoskeletal systemUnlisted procedure, shoulderUnlisted procedure, humerus or elbowUnlisted procedure, forearm or wristUnlisted procedure, hands or fingersUnlisted procedure, pelvis or hip jointUnlisted procedure, femur or kneeUnlisted procedure, leg or ankleUnlisted procedure, leg or ankleUnlisted procedure, casting or strappingUnlisted procedure, arthroscopyUnlisted procedure, noseUnlisted procedure, accessory sinusesUnlisted procedure, larynxUnlisted procedure, trachea, bronchiUnlisted procedure, lungs and pleuraUnlisted procedure, cardiac surgeryUnlisted procedure, vascular injectionUnlisted vascular endoscopy procedureUnlisted procedure, vascular surgeryUnlisted laparoscopy procedure, spleenUnlisted laparoscopy procedure, lymphatic systemUnlisted procedure, hemic or lymphatic systemUnlisted procedure, mediastinumUnlisted procedure, diaphragmUnlisted procedure, lipsUnlisted procedure, vestibule of mouthUnlisted procedure, tongue, floor of mouthUnlisted procedure, dentoalveolar structuresUnlisted procedure, palate, uvulaUnlisted procedure, salivary glands or ductsUnlisted procedure, pharynx, adenoids, or tonsilsUnlisted laparoscopy procedure, esophagusUnlisted procedure, esophagusUnlisted laparoscopy procedure, stomachUnlisted procedure, stomachUnlisted laparoscopy procedure, intestine (except rectum)Unlisted px small intestineUnlisted procedure, Meckel's diverticulum and the mesenteryUnlisted laparoscopy procedure, appendixPG0097 – 05/03/2021

78199Unlisted procedure, colonUnlisted laparoscopy procedure, rectumUnlisted procedure, rectumUnlisted procedure, anusUnlisted laparoscopic procedure, liverUnlisted procedure, liverUnlisted laparoscopy procedure, biliary tractUnlisted procedure, biliary tractUnlisted procedure, pancreasUnlisted laparoscopy procedure, abdomen, peritoneum and omentumUnlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomyUnlisted procedure, abdomen, peritoneum and omentumUnlisted laparoscopy procedure, renalUnlisted laparoscopy procedure, ureterUnlisted laparoscopy procedure, bladderUnlisted procedure, urinary systemUnlisted laparoscopy procedure, testisUnlisted laparoscopy procedure, spermatic cordUnlisted procedure, male genital systemUnlisted laparoscopy procedure, uterusUnlisted hysteroscopy procedure, uterusUnlisted laparoscopy procedure, oviduct, ovaryUnlisted procedure, female genital system (nonobstetrical)Unlisted fetal invasive procedure, including ultrasound guidance, when performedUnlisted laparoscopy procedure, maternity care and deliveryUnlisted procedure, maternity care and deliveryUnlisted laparoscopy procedure, endocrine systemUnlisted procedure, endocrine systemUnlisted procedure, nervous systemUnlisted procedure, anterior segment of eyeUnlisted procedure, posterior segmentUnlisted px extraocular muscUnlisted procedure, orbitUnlisted procedure, eyelidsUnlisted procedure, conjunctivaUnlisted procedure, lacrimal systemUnlisted procedure, external earUnlisted procedure, middle earUnlisted procedure, inner earUnlisted procedure, temporal bone, middle fossa approachUnlisted fluoroscopic procedure (e.g., diagnostic, interventional)Unlisted computed tomography procedure (e.g., diagnostic, interventional)Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)Unlisted diagnostic radiographic procedureUnlisted ultrasound procedure (e.g., diagnostic, interventional)Unlisted procedure, therapeutic radiology clinical treatment planningUnlisted procedure, medical radiation physics, dosimetry and treatment devices, and specialservicesUnlisted procedure, therapeutic radiology treatment managementUnlisted procedure, clinical brachytherapyUnlisted endocrine procedure, diagnostic nuclear medicineUnlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicinePG0097 – 05/03/2021

A9901A9999Unlisted gastrointestinal procedure, diagnostic nuclear medicineUnlisted musculoskeletal procedure, diagnostic nuclear medicineUnlisted cardiovascular procedure, diagnostic nuclear medicineUnlisted respiratory procedure, diagnostic nuclear medicineUnlisted nervous system procedure, diagnostic nuclear medicineUnlisted genitourinary procedure, diagnostic nuclear medicineUnlisted miscellaneous procedure, diagnostic nuclear medicineRadiopharmaceutical therapy, unlisted procedureUnlisted urinalysis procedureUnlisted molecular pathology procedureUnlisted multianalyte assay with algorithmic analysisUnlisted chemistry procedureUnlisted hematology and coagulation procedureSkin test; unlisted antigen, eachUnlisted immunology procedureUnlisted transfusion medicine procedureUnlisted microbiology procedureUnlisted necropsy (autopsy) procedureUnlisted cytopathology procedureUnlisted cytogenetic studyUnlisted surgical pathology procedureUnlisted miscellaneous pathology testUnlisted immune globulinUnlisted vaccine/toxoidUnlisted psychiatric service or procedureUnlisted diagnostic gastroenterology procedureUnlisted ophthalmological service or procedureUnlisted otorhinolaryngological service or procedureUnlisted cardiovascular service or procedureUnlisted noninvasive vascular diagnostic studyUnlisted pulmonary service or procedureUnlisted allergy/clinical immunologic service or procedureUnlisted neurological or neuromuscular diagnostic procedureUnlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusionUnlisted chemotherapy procedureUnlisted special dermatological service or procedureUnlisted modality (specify type and time if constant attendance)Unlisted therapeutic procedure (specify)Unlisted physical medicine/rehabilitation service or procedureUnlisted special service, procedure or reportUnlisted preventive medicine serviceUnlisted evaluation and management serviceUnlisted home visit service or procedureIncontinence supply; miscellaneousOstomy supply; miscellaneousSurgical supply; miscellaneousMiscellaneous dialysis supplies, NOSNonradioactive contrast imaging material, not otherwise classified, per studyRadiopharmaceutical, therapeutic, not otherwise classifiedMiscellaneous DME supply, accessory, and/or service component of another HCPCS codeDME delivery, set up, and/or dispensing service component of another HCPCS codeMiscellaneous DME supply or accessory, not otherwise specifiedPG0097 – 05/03/2021

V2797V2799V5299Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, traceelements and vitamins, including preparation, any strength, over 100 grams of protein - premixNOC for enteral suppliesNOC for parenteral suppliesUnclassified drugs or biologicalsDurable medical equipment, miscellaneousPET imaging, any site, not otherwise specifiedMental health services, not otherwise specifiedAlcohol and/or other drug abuse services, not otherwise specifiedUnclassified drugsUnclassified biologicsNOC drugs, inhalation solution administered through DMENOC drugs, other than inhalation drugs, administered through DMEPrescription drug, oral, nonchemotherapeutic, NOSAntiemetic drug, oral, not otherwise specifiedPrescription drug, oral, chemotherapeutic, NOSNot otherwise classified, antineoplastic drugsAddition to spinal orthotic, not otherwise specifiedSpinal orthotic, not otherwise specifiedLower extremity orthotic, not otherwise specifiedUpper limb orthotic, not otherwise specifiedLower extremity prosthesis, not otherwise specifiedUpper extremity prosthesis, not otherwise specifiedUnlisted procedure for miscellaneous prosthetic servicesProsthetic implant, not otherwise specifiedOrthotic and prosthetic supply, accessory, and/or service component of another HCPCS L codeBlood component or product, not otherwise classifiedUnspecified oral dosage form, FDA approved prescription antiemetic, for use as a completetherapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a48-hour dosage regimenMiscellaneous supply or accessory for use with an external ventricular assist deviceMiscellaneous supply or accessory for use with an implanted ventricular assist deviceMiscellaneous supply or accessory for use with any implanted ventricular assist device for whichpayment was not made under Medicare Part AInfluenza virus vaccine, not otherwise specifiedCast supplies, for unlisted types and materials of castsSplint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and othersupplies)Drug or biological, not otherwise classified, Part B drug competitive acquisition program (CAP)Integral lens service, miscellaneous services reported separatelyRepair, congenital malformation of fetus, procedure performed in utero, not otherwise classifiedPersonal care item, NOS, eachTracheostomy supply, not otherwise classifiedSupply, not otherwise specifiedNot otherwise classified, single vision lensVision supply, accessory or component of another HCPCS vision codeVision service, miscellaneousHearing service, miscellaneousREVISION HISTORY EXPLANATIONORIGINAL EFFECTIVE DATE: 02/15/2006DateExplanation & ChangesPG0097 – 05/03/2021

/01/0911/15/0901/01/1001/15/1007/12/10 01/01/1102/03/1101/01/12 02/09/16 12/14/2020 02/01/2021 05/03/2021 Additional HCPCS services added to the unlisted code reviewUpdated codesAdded E0676, K0898 and K0899 as additional unlisted valid codesUpdated codesUpdated codesAdded C9899, Q4050, Q4051, and Q4100 to unlisted reviewEffective 01/01/09, procedure code 90779 was renumbered to procedure code 96379Added codeAdded code. Effective 01/01/10, procedure code 89398 addedAdded A4335, A4421, E2599Added exceptions as procedures require invoices, which are custom; follow same unlistedprocedureAdded code, Effective 01/01/11, procedure code 88749 addedAdded codes E0446, T1505, and updated ExceptionEffective 01/01/12, procedure codes 93998, 99429 addedCombined with PG0062 Unlisted Procedure. Title changed from PG0097 Unlisted Productsto PG0097 Unlisted/Non-specific HCPCS/CPT Codes.Policy reviewed and updated to reflect most current clinical evidence per Medical PolicySteering Committee.Medical policy placed on the new Paramount Medical policy formatThe following documentation was removed from the medical policy as the procedure codes are notrelated to unlisted procedures/services, “The following HCPCS codes are not designated as unlistedprocedure codes, but are considered custom-made or non-descriptive codes. Invoices are requiredand the medical documentation must support the medical necessity for reimbursement processing,not all-inclusive: A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510,A6511, A6512, A6513, E0638, E0981, E0982, E1220, E1229, E2511, E2512, E2609, E2617, E8000,E8001, E8002, K0009, K0014, K0462, K4002, K4210, K7510, Q0505, V2623, V2624, V2625,V2626, V2627, V2628, V2629, V2785.” Where appropriate the procedure codes are identified inother medical policies.Updated medical policy documentation to the latest Industry Standards.Clarified Unlisted or not otherwise classified (NOC) and miscellaneous codes Unit Value shouldalways be one (1) (excludes unlisted DME Drug codes).Procedure S5199 defined in the list of procedure codes, as procedure S5199 is documented in thegreen box as non-covered.REFERENCES/RESOURCESCenters for Medicare and Medicaid Services, CMS Manual System and other CMS publications andservicesOhio Department of MedicaidAmerican Medical Association, Current Procedural Terminology (CPT ) and associated publications andservicesCenters for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCSRelease and Code SetsHayes, Inc.PG0097 – 05/03/2021

PG0097 - 05/03/2021 CPT/HCPCS CODE The following CPT/HCPCS procedure codes require supporting documentation (this list may not be all-inclusive): 01999 Unlisted anesthesia procedure(s) 15999 Unlisted procedure, excision pressure ulcer 17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue 19499 Unlisted procedure, breast .