September 27, 2022
When billing with unlisted or miscellaneous codes on claims submitted to Blue Cross and Blue Shield of Illinois (BCBSIL), you can avoid additional documentation requests by describing the specific drug, service, supply or procedure provided. This will help avoid processing delays or denials, and unnecessary requests for medical records and/or supporting documentation.
What are unlisted or miscellaneous codes?
These are codes labeled as Non-Specified, Not Listed, Not Elsewhere Specified (NEC), Not Otherwise Classified (NOC), Not Otherwise Specified (NOS), Unclassified, Unlisted, or Unspecified.
Some unlisted or miscellaneous codes could require prior authorization to determine coverage and benefits. Be sure to check eligibility and benefits via Availity® Essentials or your preferred vendor to confirm prior authorization requirements and vendors, if applicable. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
For commercial non-HMO members, even if prior authorization isn’t required, some procedures/services not specifically defined or classified may be subject to contract/clinical review. Refer to the Medical Policy Reference List on our Predetermination page for details.
If you submit a prior authorization or predetermination request that includes an unlisted or miscellaneous code, be sure to include a detailed description of the service. along with any documentation to support your request. This step helps avoid the need for post-service medical necessity review.
Refer to our Utilization Management section for more information, such as how to submit electronic requests for prior authorization and predetermination.
Claims submitted with an unlisted or miscellaneous code without a description are typically denied for lack of supporting documentation. Get your claims processed faster by submitting a pre-service request as noted above and/or including a description of the specific drug, service, supply or procedure on your claim.
When using unlisted or miscellaneous codes on claims for BCBSIL members:
- Use the most specific unlisted code that’s available if a code doesn’t exist that accurately describes the drug, service, supply or procedure.
- Describe the service and include documentation when submitting claims with codes that are identified as “unlisted” or “miscellaneous.”
For More Information
Refer to BCBSIL’s Clinical Payment and Coding Policies (CPCPs) page to view CPCP035, Unlisted/Not Otherwise Classified Coding. CPCP035 includes examples of supporting documentation that should be included. For general claim-related information, refer to our Claim Submission page.
This material is for educational purposes only and is not intended to be a definitive source for coding claims. Health care providers are instructed to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. Checking eligibility and/or benefit information and/or obtaining prior authorization or pre-notification is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors and the products and services they offer.