Unlisted CPT/HCPCS Codes

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July 31, 2017

Unlisted CPT/HCPCS Codes

Effective September 1, 2017, Mercy Care Plan and Mercy Maricopa will change the way unlisted and non-specific CPT and HCPCS codes are reviewed and paid.

With a few exceptions listed below, these codes will no longer be managed through the prior authorization process. They will be managed By Report at the time of claim submission. That is, records supporting the use of these codes must be submitted with the claim. These claims will pend to our AMA Edit Team who will review for:

Experimental/Investigational status per relevant Clinical Policy Bulletins; and
Medical necessity applying relevant criteria; and
Assignment of a more appropriate specific code if one exists; or
Approval to pay as submitted.

Codes not included in the process change are:

41899 - General Anesthesia for dental procedures - Prior Authorization Required
E1399 and K0108 - wheelchair components and services -Prior Authorization Required
90999 - unlisted dialysis procedure - Prior Authorization Required
Unlisted J codes - Prior Authorization Required

Please refer to our Unlisted and Non-Specific CPT and HCPCS Codes Subject to Prepayment Review reference guide for a listing of all codes that are subject to prepayment review. If medical records are not submitted with your claim, the claim will be denied for lack of documentation. You may resubmit the claim with required supporting records.

As always, don't hesitate to contact your Mercy Care or your Mercy Maricopa Provider Relations Representative with any questions or comments. You can find this notice and all other provider notices on our Mercy Care Plan or Mercy Maricopa website.

Thanks for all you do!

QB 2890