What must be included with a claim when using an unlisted CPT code?

When submitting a claim that includes an unlisted CPT code, it is essential to include a detailed description of the procedure performed. Unlisted codes are specific to procedures that do not have a designated CPT code, meaning the coder must provide sufficient information to justify the use of that particular code. The detailed description helps the insurance provider understand exactly what was done during the procedure and why it was necessary. This information is crucial for ensuring that the claim is accurately processed and has the best chance of being reimbursed.

The other options, while they could be relevant in some contexts, do not fulfill the specific requirement for submitting unlisted codes. For example, a history of previous procedures may provide additional context but does not sufficiently describe the current procedure. Similarly, a copy of the patient's insurance policy is not relevant to the procedure itself, nor is a report from the performing specialist strictly required when submitting claims, although it may occasionally aid in clarifying the details of the procedure when needed. Overall, a detailed description is the primary need to support the use of unlisted CPT codes effectively.