Unlisted Procedure or Service

When billing an unlisted code, the claim must include a description of the service or item.  Appropriate medical records (such as the operative report) for services; and documentation of the item provided (including the make, model and manufacturer) along with an invoice for equipment, supplies, orthotics/prosthetics. The full NDC number must be submitted when billing for a drug/biologic.  

For professional claims, if the unlisted CPT/HCPCS code has not been assigned relative values by CMS and no other fee schedule amount has been set by Blue Cross and Blue Shield of Nebraska, a comparable code may be used to determine the rate for the unlisted code.