Unlisted Codes and Required Information

In following TRICARE requirements as well as industry standards, TriWest Healthcare Alliance Corp. (TriWest) requires additional information if unlisted codes or not otherwise categorized (NOC) codes are billed on a claim.

Here is a chart of categories with examples of CPT codes, text description required, and documentation required. If a text note or documentation is required, TriWest prefers that the text is entered on the electronic claim rather than submitting the documentation. Please remember that prior authorization is required for all unlisted codes.

Category of Unlisted Procedures	CPT Code Examples	Required Text, Documentation, Both or Either	Text Description Required	Documentation Required
Radiology	76498, 76499	Either	Detailed description of the approved radiology procedure	Radiology report
Radiation Therapy	77799, 78299	Documentation		Report signed by the physician indicating what services were performed
Laboratory	87899, 88199	Documentation		Laboratory report
Pathology	88399, 89240	Documentation		Pathology report pointing out the specific test used

Source: https://vapccc.triwest.com/PCCCWeb/index.html#/provider-home