52 terms

CPT Chapter 8

procedure/service coding reference developed by CMS
Health care common procedure coding system (hcpcs)
Two levels of codes are asscoiated with hicpcs , referred to as
hcpcs level I and II codes
HCPCS level I includes the 5 digit CPT codes developed & published by
American Medical Association
HCPCS level II were created in 1983 to describe
common medical services & supplies not classified in CPT
HCPCS level II national codes
are 5 characters in length & begin with letters A-V
HCPCS level II codes identify services performed by
physician & nonphysician providers, ambulance companies, & Durable Medical Equipment (DME) companies
Durable Medical Equipment (DME)
defined by Medicare as equp. that can withstand repeated use, is primarily used to serve a medical purpose, is used in the patient's home & would not be used in the absence of illness or injury
When an appropiate HCPCS level II code exisits
it is often assigned instead of a CPT code (with the same or simialr code description for MEDICARE accounts & for some state Medicaid systems
Coders should check with
individual payers to determine their policies
CMS creates
HCPCS level II codes
New HCPCS level II codes are reported for several years untill
CMS initiates a process to create corresponding CPT codes
When CPT codes are published they are reported
instead of the original HCPCs level II codes
Medicaid Programs use HCPCS codes to report
professional services , procedures, supplies, & equipment
HCPCS is NOT a reimbursement methodology or system, & it is important
to understand that just because codes exist for certain procedures or services, coverage (payment) is not guaranteed
it ensures uniform reporting of
(HCPCS level II coding system charcteristics)
medical procedures or services on claim forms
code descriptors identify
(HCPCS level II coding system charcteristics)
similar products or services
HCPCS is not a reimbursement methdology for making
(HCPCS level II coding system charcteristics)
coverage or payment determinations
Effective JAN. 1st 2005, CMS no longer allows
90 day grace period for reporting discontinued, revised and new HCPCS level II national codes on claims
Types of HCPCS level II codes
permanent national codes, dental , misc., temp. codes, & modifiers
HCPCS level II Permanent national codes are maintained by HCPCS national panel, which is composed of
representitves form Blue Cross/Shield Asscociation, Health Insurance of America and CMS
HCPCS national Panel I responsible for making decisions about
additions, revisions, and deletions to the permanent national alphanumeric codes
dental codes
actually contained in Current Dental erminology , a coding manual copyrighted and published by the American Dental Association that lists codes for billing for dental procedures and supplies
Miscellanous codes
reported when a DMEPOS dealer submits a claim for a product or service which there's no exsiting HCPCs level II code
Claims that contain miscellanous codes are
manually reviewed by the payer
Following must be provided for use in the review process
Complete description of product or service,
Pricing info for product of service,
Documentation to explain why the item or service is needed by the benificery
Temporary codes
maintianed by CMS & other members of the HCPCS national panel, independent of permanent HCPCS level II codes
Permanent codes are updated once a year on Jan 1st but temp. codes allow
payers the flexibility to establish codes that are needed before the next jan. 1st anual update
Whenever a permanent code is established by the HCPCS national panel to
replace a temp code, the temp code is deleted and cross-refrenced to the new permanent code
If permanent codes are not established
temp codes "remian temporary" indefintly
C codes identify items that may qualify for transitional pass-through payments
under the hospital Outpatient Prospective Payent System (OPPS)
Over and above
the OPPS payment
Codes are used exclusivley for OPPS purposes & are only valid for
Medicare claims submitted by hospital outpatient departments
G codes identify
professional healthcare procedures & services that do not have codes identified in CPT
S codes are used by the BCBSA & the HIAA when no
HCPCS level II codes exisit to report drugs, services, & supplies, but codes are needed to be implement private payer policies & programs for claims processing
HCPCS modifiers
clarify services & procedures performed by providers
Modifiers indicate that the
description of service or procedure performed has been altered
HCPCS modifiers are reported as
to digit character alphabetic or alphanumeric codes added to the 5 character HCPCs level II code
ex: Modifier -UE indicates
product is "used equipment"
anesthesia services performed personally by anesthesiologist
Ophythalmological examination
lower right, eyelid
Table of drugs : J codes is for
C codes are reported for
new drugs, bilogicals, & devices that are eligible for transitional passthrough payments
It is important never to code directly from the
index & always to verify the code in the tabular section of the coding manual
If you have difficulty locating the service or procedure in the HCPCS level II index
review the contents of the appropiate section to locate the code
HCPCS level II code determines wheter the claim is sent to the
local Medicare administrative contractor or the regional
D, G, M, P, or F are
reported to the local MAC
Some serivce \s must be reported
by assigning both a CPT and HCPCS code
Unless the payer or insurance plan adivises the provider that it does not pay seperatly for the
medication injected, always report this combination of codes
Medicare gives HCPCS level II codes the highest priorty if the CPT code is
general & the HCPCS level II code is more specific
Most supplies are included in the charge for the
office visit or the procedure
CPT providers code 99070 for all supplies & materials exceding those
usually included in the primary service or procedure performed