Unlisted Procedure and Not Otherwise Classified Codes: Noridian

Processing Changes: Effective 9/16/13, items requiring an invoice must follow the below criteria. Faxes will only be reviewed for PWK processing.
When billing for a service or procedure, select the CPT, HCPCS, or drug code that accurately identifies the service or procedure performed. If no such code exists, then report the service or procedure using the appropriate "unlisted procedure code or Not Otherwise Classified (NOC) code (which often end in 99). Noridian will not correctly code unlisted codes when a valid code is available.

Correct Coding Guidelines

• It is the responsibility of the provider to ensure all information required to process unlisted procedure codes or (NOC) codes is included on the CMS-1500 form or the electronic media claim (EMC) when the claim is submitted.
• If required information is missing, the code will be denied or deemed unprocessable.
• Descriptions of the unlisted procedure codes include, but are not limited to, narratives, trip notes for ambulance claims, etc.
• Enter a concise description of the services rendered in Item 19 on the CMS-1500 claim form. If the description does not fit in Item 19, an attachment describing the services must be submitted for providers who submit paper claims.
• When submitting attachments (e.g., operative report, office notes, invoices) to support the unlisted code billed, unless it is immediately evident, identify the unlisted procedure with a written description, or by underlining or marking the billed service on the attachments. Highlighters should not be used as this obliterates the text and is not visible after the document is photocopied or scanned.
• The electronic equivalent for Item 19 on EMC submissions will hold up to 80 characters for the concise statement and should be enough space to describe the unlisted procedure code.

Unclassified Drug Billing

The following unclassified drug codes should be used only when a more specific code is unavailable:

• J3490 Unclassified drugs
• J3590 UNCLASSIFIED BIOLOGICS
• J9999 Not otherwise classified, anti-neoplastic drug

When submitting a claim using one of the codes listed above, enter the drug name and dosage in Item 19 on the CMS 1500-claim form or the electronic equivalent. Pricing will be based on the information entered in these fields. The quantity-billed field must be entered as one (1).

Compound Drug Billing Exception

An exception to the unclassified drug code instruction above is the billing of compound drugs (often prepared by special pharmacies), which should be billed as outlined in the companion articles published simultaneously with this article:

• Compounded Drugs Reimbursement Billing Revised – November 2011
• Infusion Drugs Reimbursement Billing Revised – November 2011

If there is a valid J-code for the drug billed, the unlisted code will not be correctly coded by Noridian. The unlisted code will be denied as a billing error. Medicare payment will be based on the information submitted. If the required information is not submitted, any unlisted procedure or service will be denied as unprocessable.
Source: Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 26, Section

Courtesy of Noridian https://www.noridianmedicare.com/je/docs/unlisted_procedure_and_not_otherwise_classified_codes.html