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HS 225 Unit 5 Presentation

Chapter 23: HCPCS Codes

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Overview

Healthcare Common Procedure Coding System is referred to using the acronym HCPCS,

Two levels HCPCS level I HCPCS level II

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HCPCS Level I

Five-digit CPT codes and two-digit modifiers

Developed by American Medical Association (AMA)

Updated annually-Jan. 1

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HCPCS Level II

HCPCS national codes and two-character modifiers

Describe common medical services and supplies not classified in CPT

Five characters in length Begin with letters A–V, followed by four

numbers For example, abdominal aneurysm wrap

(M0301)

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Durable Medical Equipment (DME)

Can withstand repeated use Primarily used to serve a medical

purpose Used in patient’s home Would not be used in the absence of

illness or injury

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HCPCS Level II National Codes

Classify similar medical products and services for claims processing

Each code contains a description: DME Medications Provider services Temporary Medicare codes (e.g., Q codes) Other items and services (e.g., ambulance)

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HCPCS Level II National Codes

HCPCS National Panel responsible Panel consists of:

Blue Cross/Blue Shield Association Health Insurance Association of America CMS

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Certificate of Medical Necessity for DME

A Certificate of Medical Necessity clearly explains why a physician feels a patient needs the DME item or service.

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Advance Beneficiary Notice

Waiver signed by patient Acknowledges that, since medical

necessity for a procedure, service, or supply cannot be established, patient accepts responsibility for reimbursing provider or durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) dealer for costs associated with procedure, service, or supply.

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HCPCS Level II Coding Tips

The coder should be sure that a HCPCS Level I code is not available before assigning a HCPCS Level II code.

The coder needs to read the selected code carefully because some codes indicate “each” or “per,” so the quantity reported may need to be more than one (1)

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HCPCS Level II

Organized by type Permanent national codes Miscellaneous codes Temporary codes Modifiers

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HCPCS Level II

Medical and Surgical Supplies (A4000-A8999)

Administrative, Miscellaneous and Investigational (A9000-A999)

Enteral and Parenteral Therapy (B4000-B9999)

Dental procedures (D0000-D9999)

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HCPCS Level II

DME (E0100-E999) Procedures/Professional Services

(Temporary) (G0000–G9999) Alcohol and/or Drug Abuse Treatment

Services (H0001–H2037) Drugs Administered other than Oral

Method (J0000–J9999)

(continued)

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HCPCS Level II

Temporary codes (K0000-K9999) Orthotic Procedures (L0000–L4999) Prosthetic Procedures (L5000–L9999) Medical Services (M0000–M0301) Pathology and Laboratory Services

(P0000–P9999)

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HCPCS Level II J CodesPermission to reuse in accordance with http://www.cms.hhs.gov Web site Content Reuse Policy.

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HCPCS Level II

Q codes (temporary) (Q0000–Q9999) Diagnostic radiology services (R0000–

R5999) Temporary national codes (non-

Medicare)(S0000-S9999) National T codes established for state

Medicaid agencies (T1000–T9999) Vision services (V0000-V2999) Hearing services (V5000-V5999)

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CPT Symbols

Bullet located to the left of code identifies new procedures and services (●)

Triangle located to the left of code identifies revision of code description (▲)

Horizontal triangles surround revised guidelines and notes (►◄)

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Level I & II Modifiers

Clarify services and procedures performed by providers

Reported as two-digit numeric codes added to five-digit CPT code

HCPCS level II national two-digit alpha-numeric modifiers also are added to five-digit CPT code

Not all codes require modifiers

(continued)

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Special E/M Cases

-21 Prolonged E/M services -24 Unrelated E/M service by same

physician during postoperative period -25 Significant, separately identifiable

E/M service by same physician on same day of procedure or other service

-57 Decision for surgery

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Greater, Reduced, or Discontinued Services

-22 Increased procedural services -52 Reduced services -53 Discontinued procedure -73 Discontinued outpatient

hospital/ambulatory surgery center procedure prior to anesthesia

(continued)

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Greater, Reduced, or Discontinued Services

-74 Discontinued outpatient hospital/ambulatory surgery center procedure after anesthesia administration

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Global Surgery

-54 Surgical care only -55 Postoperative management only -56 Preoperative management only

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Special Surgical and Procedural Events

-58 Staged or related procedure or service by same physician

-59 Distinct procedural service -63 Procedure performed on infants

less than 4 kilograms (kg)

(continued)

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Special Surgical and Procedural Events

-78 Return to operating room for related procedure during postoperative period

-79 Unrelated procedure or service by same physician during postoperative period

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Bilateral and Multiple Procedures

-50 Bilateral procedure -27 Multiple outpatient hospital E/M

encounters on same date -51 Multiple procedures

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Repeat Services

-76 Repeat procedure by same physician

-77 Repeat procedure by another physician

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Multiple Surgeons

-62 Two surgeons -66 Surgical team -80 Assistant surgeon -81 Minimum assistant surgeon -82 Assistant surgeon (when qualified

resident not available)

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Professional and Technical Components

-26 Professional Component

-TC Technical Component

(found in HCPCS level II manual)

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Mandated Services

-32 Mandated services

-23 Unusual anesthesia

-47 Anesthesia by surgeon

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Laboratory Services

-90 Reference (outside) laboratory

-91 Repeat clinical diagnostic laboratory test

-92 Alternative laboratory platform testing

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Multiple Modifiers

-99 Multiple modifiers Used to alert third

party payer that there are more than four modifiers on the CPT

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Questions