What must be sent along with an unlisted code to justify the service performed?

When submitting a claim that includes an unlisted code, it is essential to provide additional documentation that supports the services billed. One of the most important documents to include is a copy of the operative note. This note contains detailed information about the procedure performed, including its complexity and any unique circumstances. By providing this documentation, the medical office can clearly justify the need for the unlisted code and help ensure that the claim is processed accurately.

The operative note serves to give insurance companies or payers a comprehensive understanding of the procedure, which may not be fully described by standard codes. It helps clarify why the unlisted code was necessary and how it relates to the patient’s specific case. This thoroughness is vital in mitigating potential payment denials or delays due to insufficient information.

The other options do not provide the specific justification needed for unlisted codes. A verbal account of the visit lacks the formal documentation required in a claim. An add-on code may not be applicable if it does not relate directly to the unlisted service in question. Modifiers are used to provide additional details about the service or procedure performed but do not serve as justification in the same way the operative note does.