Sample Prior Authorization, Cover Letter, or Appeal Letter for the Otolaryngologist’s Use of an Unlisted CPT Code for Endoscopic/Endonasal Skull Base Surgery

To Whom It May Concern: Attached is a copy of Dr. _____’s operative note and CMS 1500 claim form to support the use of an unlisted Current Procedural Terminology® (CPT) code for the procedure(s) performed. There are no CPT codes for endoscopic skull base surgery; therefore, I used CPT 31299 (unlisted procedure, nervous system) for my endoscopic definitive procedure of the skull base tumor resection and closure. The CPT guidelines instruct physicians not to select a CPT code that merely approximates the service provided. Additionally, CPT guidelines state if no such procedure or service exists, then the appropriate unlisted procedure or service code is reported. We are following CPT guidelines by reporting an unlisted CPT code, 31299, because the current skull base CPT codes do not describe an endoscopic/endonasal procedure. The following table, below left, shows the procedures performed and represented by the CPT code billed and the surgeon’s fee using the appropriate unlisted code. The table below on the right shows a comparison to the current “open” skull base surgery CPT code and our associated fee so you will understand how we derived our charge for this patient’s procedure. [Add the following statement if the fee reflects a zero-day postoperative global period: Please note that there is no postoperative global period assigned to unlisted CPT codes; therefore, I will be separately reporting all necessary follow-up care including hospital care (9923x), office visits (9921x), endoscopic sinus debridements (31237), and nasal endoscopy (31231).] [Add the following statement if the fee reflects a 90-day postoperative global period: Please note that I have included in the fee all postoperative care for 90 days as is included in the comparative base open CPT code(s) listed above. This includes at least three hospital days and two office visits with endoscopic sinus debridements performed bilaterally (31237-50).] Procedure Performed/Unlisted CPT Code/Our Fee Comparative Base Open CPT Code(s)/Our Fee CPT 31299 Unlisted procedure, nervous system (List name of endoscopic procedure here as written by the physician on the operative note) Fee: $ CPT (list the codes, descriptions, and fees for the codes used in comparison) Fee: $ Thank you in advance for kindly processing this claim in an expeditious and appropriate manner. Sincerely, Dr. Otolaryngologist