Who requires a special report with the use of unlisted codes?

The correct answer is that third-party payers require a special report when unlisted codes are used. Unlisted codes are typically not associated with specific procedures or services as defined in the standard coding manuals. When a healthcare provider uses an unlisted code, it signifies that a particular service or procedure was performed that is not captured by existing codes.

Third-party payers, which include private insurance companies and Medicare/Medicaid, require additional documentation to justify the use of these unlisted codes. The special report should provide a detailed explanation of the service rendered, reasoning for why an unlisted code is appropriate, and any relevant information that supports the medical necessity of the service. This information is critical for the payer to evaluate the claim and decide whether reimbursement is warranted.

Government agencies, healthcare providers, and insurance companies may have their own guidelines and requirements, but the specific need for a special report directly pertains to the interactions between healthcare providers and third-party payers regarding unlisted codes. Thus, the emphasis is on the role of third-party payers in ensuring that claims using unlisted codes are substantiated with adequate documentation.