What is the correct action if a procedure performed is not listed in the CPT codebook?

Selecting an unlisted procedure code is the appropriate action when a procedure performed is not specifically listed in the CPT codebook. Unlisted procedure codes are designed for situations where a service or procedure is not available in the standard codes. By using an unlisted code, coders can indicate that a procedure was performed, even though a specific code does not exist for it.

This choice allows coders to properly document the service provided and ensures that the payer is aware of the specific treatment rendered. It also enables the healthcare provider to receive reimbursement for the procedure, as the claim will be based on the details provided in the documentation and supported by the use of the unlisted code.

Unlisted codes require that additional information is often submitted to justify the use of the code, making documentation and a clear description of the procedure crucial. This is important for claims review and for the payer to understand why the unlisted procedure was necessary.

Using a related procedure code or asking the patient for a code would not accurately reflect the services rendered and could lead to denial of a claim or incorrect coding, while simply documenting the procedure without coding leaves the service inadequately represented in billing.