Medicare typically sets payment rates for physician services using relative values. The values are published annually in the Physician Fee Schedule. In the case of an unlisted code, CMS instructs the Medicare contractors to develop their own value for the service. This means that each contractor determines reimbursement for the use of this technology in their region. When submitting an unlisted code it is likely that the Medicare contractor will ask for further information in order to set a payment such as:

• the patient's chart notes
• a letter of medical necessity (LMN)
• the physician's charge for the service

The physician may choose to set charges for the service represented by the unlisted code based on charges established for comparable services. If you have any questions about this, please contact usreimbursement@deltexmedical.com

Private payers have their own methodologies for setting payment rates for unlisted codes. Some have written policies for unlisted codes. Others refer to the negotiated rate (i.e. a percentage of charges) included in the provider contract.

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