Quartz adheres to AMA CPT guidelines for unlisted codes. Unlisted CPT codes can be useful for documenting services that don’t have a specific code, but they should be used with care. These codes are valid across all care settings and lines of business and should only be used when no existing CPT code accurately describes the service. To avoid delays or denials, it’s important to follow these guidelines:

• Use only when necessary: Unlisted codes should be rare and only used if no specific code applies.
• Include a clear description: Whether submitting a prior authorization or claim, describe the service in detail.
• Prior authorization is not guaranteed: Requests must clearly outline the service.
  • Note: Quartz Medicare Advantage members may not require prior authorization, depending on the service.
• All claims require documentation: Unlisted codes are subject to review. Incomplete submissions can lead to delays or denials.
• Electronic vs. paper submissions:
  • Electronic claims: Enter the description in the appropriate field.
  • Paper claims: Ensure the description is complete and legible (e.g., Box 19 on CMS-1500).
• Coverage and reimbursement may vary: Unlisted codes are not separately reimbursable in all cases, but they can be billed on their own if the service is the only one provided. Prior authorization may not always be required, depending on the service and line of business.

More information

See the Unlisted Procedures and Services Policy & Procedure (Quartz Provider Manual, page 130) for full details. This policy and procedure relates to billing and coding only and does not address medical necessity.
Questions? Contact Customer Success via My Quartz Tools or call (800) 897-1923.