CMS Pub. 100-04, ch. 13, § 120

Billing Instructions for A/B MAC (A) Claims

(Rev. 1, 10-01-03)

Some radiology and other diagnostic services may not have a corresponding HCPCS

code. This is because these are typically services that are rarely provided, unusual, or

new. The provider should assign the appropriate “unlisted procedure” code to any such

service. The following list contains the “unlisted procedure” codes along with the

suggested revenue code for billing. These services are paid on a fee schedule if one

exists or cost if a fee has not been established for SNFs. However, before billing any of

these codes the provider needs to furnish a complete description of the radiology

procedure to the A/B MAC (A) for review and analysis. The description should include a

narrative definition of the procedure and a description of the nature, extent and need for

the procedure and the time, effort, and equipment necessary. The A/B MAC (A) will

determine if the provider has correctly identified the procedure as “unlisted.” If the

procedure is not identified correctly, the A/B MAC (A) will inform the provider of the

correct HCPCS code to assign to the procedure. If there is no fee schedule amount

established, these services are paid based on cost to SNFs.

For Radiology:

Revenue Code HCPCS Definition

032x 76499 Unlisted diagnostic radiologic procedure

0402 76999 Unlisted ultrasound procedure

0333 77299 Unlisted procedure, therapeutic radiology clinical

treatment planning

Revenue Code HCPCS Definition

0333 77399 Unlisted procedure, medical radiation physics, dosimetry

and treatment devices

0333 77499 Unlisted procedure, therapeutic radiology clinical

treatment management

0333 77799 Unlisted procedure, clinical brachytherapy

034x 78099 Unlisted endocrine procedure, diagnostic nuclear medicine

034x 78199 Unlisted hematopoietic, reticuloendothelial and lymphatic

procedure, diagnostic nuclear medicine

034x 78299 Unlisted gastrointestinal procedure, diagnostic nuclear

medicine

034x 78399 Unlisted musculoskeletal procedure, diagnostic nuclear

medicine

034x 78499 Unlisted cardiovascular procedure, diagnostic nuclear

medicine

034x 78599 Unlisted respiratory procedure, diagnostic nuclear

medicine

034x 78699 Unlisted nervous system procedure, diagnostic nuclear

medicine

034x 78799 Unlisted genitourinary procedure, diagnostic nuclear

medicine

034x 78999 Unlisted miscellaneous procedure, diagnostic nuclear

medicine

034x 79999 Unlisted radiopharmaceutical therapeutic procedure

For Other Diagnostic Procedures:

Revenue Code HCPCS Definition

075x 91299 Unlisted diagnostic gastroenterology procedure

047x 92599 Unlisted otorhinolaryngological service or procedure

048x 93799 Unlisted cardiovascular service or procedure

Revenue Code HCPCS Definition

073x 93799 Unlisted cardiovascular service or procedure

0921 93799 Unlisted cardiovascular service or procedure

046x 94799 Unlisted pulmonary service or procedure

074x 95999 Unlisted neurological or neuromuscular diagnostic

procedure

0922 95999 Unlisted neurological or neuromuscular diagnostic

procedure

130 - EMC Formats

(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid

Tumors: June 11, 2013, ICD-10: Upon Implementation of ICD-10

Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron

Emission Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared

System Edits; July 7, 2014 - CWF development/testing, FISS requirement

development; October 6, 2014 - CWF, FISS, MCS Shared System Edits), ICD-10:

Upon Implementation of ICD-10)

Billing instructions for the ASC X12 837 institutional claim format can be found in

chapter 24 of this manual or, for Form CMS-1450 can be found in chapter 25 of this

manual. Each revenue code requires a HCPCS code, modifier if applicable, units, line-item date of service, and charge.

Billing instructions for the ASC X12 837 professional claim format can be found in

chapter 24 of this manual or for Form CMS-1500 can be found in this manual, Chapter

26, “Instructions for Completing Form CMS-1500."