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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

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