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FAQ

Unlisted Codes and Required Information

6/7/2012

In following TRICARE requirements as well as industry standards, TriWest Healthcare Alliance (TriWest) requires additional information if unlisted codes or not otherwise categorized (NOC) codes are billed on a claim.

Here is a chart of categories with examples of CPT codes, text description required, and documentation required. If a text note or documentation is required, TriWest prefers that the text is entered on the electronic claim rather than submitting the documentation. Please remember that prior authorization is required for all unlisted codes.

Category of Unlisted Procedures	CPT Code Examples	Required Text, Documentation, Both or Either	Text Description Required	Documentation Required
Anesthesia	01999	Documentation		Surgeon’s operative report
Surgery	15999, 17999	Documentation		Surgeon’s operative report
Procedure	36299, 38999	Either	Detailed description of the approved procedure	Procedure report
Radiology	76498, 76499	Either	Detailed description of the approved radiology procedure	Radiology report
Radiation Therapy	77799, 78299	Documentation		Report signed by the physician indicating what services were performed
Laboratory	87899, 88199	Documentation		Laboratory report
Pathology	88399, 89240	Documentation		Pathology report pointing out the specific test used
Drugs	J3490, J7199, C9399	Text	Drug name, unit of measure (MG, ML or UN), drug quantity, and National Drug Code (NDC) if applicable
E&M	99429, 99499	Text	Detailed description of the approved office service performed
Home Services	99600	Text	Detailed description of the approved services
Supplies/DME	L8699, E1399	Documentation		Supplier’s Invoice
Enternals/ Parenterals	B9998, B9999	Documentation		Supplier’s Invoice
Ambulance	A0999	Text	Detailed description of services

Effective Dec. 1, 2010, TriWest implemented a change in reimbursement for supplies and durable medical equipment (DME) billed with an unlisted code. Payment is based on the invoice plus 20 percent to a maximum of $2,000 per claim. A complete list of unlisted codes and the required text and/or documentation is available in the Reimbursement Rates section on TriWest.com/Provider.

For more information, please refer to the Claims/Payment section of TriWest.com/Provider.