Chapter 7: HCPCS Level II National Coding System Unit 5 Presentation Chapter 7: HCPCS Level II National Coding System

Overview Three levels HCPCS level I HCPCS level II HCPCS level III 2

HCPCS Level I Five-digit CPT codes and two-digit modifiers Developed by American Medical Association (AMA) Updated annually-Jan. 1 3

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) Identify services by physician and non physician providers (NP, Pas, therapists), ambulance services, and DME 4

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 Defined by Medicare as equipment that: 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 DMEPOS-durable medical equipment, prosthetics, orthotics and supplies dealers-supply patient with DME Canes Crutches Wheelchairs Walkers Commode chairs Glucose monitors 5

HCPCS Level III Effective December 31, 2003, HCPCS level III local codes are no longer reported. 6

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) 7

HCPCS Level II National Codes HCPCS National Panel responsible Panel consists of: Blue Cross/Blue Shield Association Health Insurance Association of America CMS HCPCs maintained by the national panel: Blue Cross/Blue Shield Association Health Insurance Association of America CMS 8

Common HCPCS Level II References General guidelines and instructions Appendix (e.g., additions, deletions) Table of drugs or deleted codes Symbols Special coverage instructions Current national modifiers Reverences for HCPCS Level II codes include: General guidelines and instructions Appendix (e.g., additions, deletions) Table of drugs or deleted codes Symbols Special coverage instructions Current national modifiers 9

HCPCS Level II Organized by type Permanent national codes Dental codes Miscellaneous codes Temporary codes Modifiers Permanent national codes-maintained by HCPCs National Panel Dental codes-include dental procedures and supplies, maintained by American Dental Association Miscellaneous codes-codes that are reported when a DMEPOS dealer submits a claim for a product that has no HCPCs Level II Code Temporary codes- maintained by CMS and other member of HCPCs panel, updated more than once a year, can be replaced by a permanent code Modifiers-Attach to CPT (level I) or HCPCS (level II) codes 10

HCPCS Level II Modifiers Attached to any HCPCS level I or II code Provide additional information Not all codes require modifiers 11

HCPCS Level II Index Entries Permission to reuse in accordance with http://www.cms.hhs.gov Web site Content Reuse Policy. 12

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) Supplies, devices (hip replacement, pacemaker), drugs 13

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) 14

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) 15

HCPCS Level II J Codes Permission to reuse in accordance with http://www.cms.hhs.gov Web site Content Reuse Policy. 16

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) 17

Determining Payer Responsibility Specific code determines where claim is sent Medicare administrative contractor (MAC) DME Medicare administrative contractor (MAC) Annual list of billing codes and billing instructions MAC-government agency that process medical claims DME MAC- process DME claims Providers and DMEPOS dealers obtain an annual list of valid national codes that include the billing instructions for services. 18

Patient Record Documentation Justifies medical necessity of procedures, services, and supplies coded and reported Documentation should include: Patient history, including review of systems (ROS) Physical examination Diagnostic test results Diagnoses (duration and comorbidity) Prognosis 19

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 20

DMEPOS Claims Certificate of medical necessity Prescription for DME, services, and supplies DME MAC medical review policies Include local and national coverage determinations For certain claims DMEPOS must get a Certificate of medical necessity Must be kept on file DME MAC medical review policies They define the coverage criteria, payment rules, and documentation requirements for DME equipment Must fall within a benefit category Not be excluded by statute or by national CMS policy Be reasonable and necessary to diagnose and/or treat an illness or injury or to improve the functioning of a malformed body. 21

Introduction to CPT Coding Chapter 8 Introduction to CPT Coding

History of CPT 1966 1970 1983 1986 1996 2004 Published by AMA Five-digit codes 1983 Adopted as part of HCPCS 1986 Omnibus Budget Reconciliation Act (OBRA) 1996 HIPAA 2004 MMA (continued) 23

CPT Mandated Reporting Home health care and hospice agencies Outpatient hospital departments Physicians who are employees of a health care facility Physicians who see patients in their offices or clinics and in patients’ homes These facilities are mandated to use CPT 24

Nonreportable Services Considered integral to procedure No separate code reported For example: Administering sedatives Cleansing, shaving, and prepping of skin Draping and positioning of patient Irrigating a wound Inserting and removing drains 25

CPT-5 Fifth edition Codes remain five digits in length Changes include: Support of electronic data interchange (EDI), computer-based patient record (CPR), or electronic medical records (EMR) Tracking of new technology and performance measures Glossary Electronic index (under development) 26

CPT Categories Category I codes Category II codes Category III codes Procedures and services Category II codes Performance measures Category III codes Emerging technology 27

Organization of CPT Six sections: Evaluation and Management (E/M) (99201–99499) Anesthesia (00100–01999, 99100–99140) Surgery (10021–69990) Radiology (70010–79999) Pathology and Laboratory (80048–89356) Medicine (90281–99199, 99500–99602) 28

CPT Index Alphabetic main terms Boldfaced Represent procedures or services, organs, anatomic sites, conditions, eponyms, or abbreviations Subterms indented below 29

Selection from CPT Index Current Procedural Terminology © 2008 American Medical Association. All rights reserved. 30

CPT Index Organization Procedures or services (e.g., endoscopy) Organs or other anatomic sites (e.g., elbow) Conditions (e.g., wound) Synonyms (e.g., finger joint or intercarpal joint) Eponyms (e.g., Whitman procedure) Abbreviations (e.g., MRI) (continued) 31

CPT Index Boldfaced type Italicized type Main terms, categories, subcategories, and code numbers Italicized type Cross-reference terms (e.g., see) Directs coders to index entry under which codes are listed 32

Appendices Appendix A Appendix B Appendix C List of modifiers and descriptions Appendix B Annual CPT coding changes Appendix C Clinical examples for codes found in E/M section (continued) 33

Appendices Appendix D Appendix E Appendix F List of add-on codes Identified with plus symbol (+) Appendix E List of codes that are exempt from modifier -51 Appendix F List of codes that are exempt from modifier -63 (continued) 34

Appendices Appendix G Appendix H Summary of CPT codes identified with bull’s eye symbol () Codes that include Moderate (Conscious) Sedation (MCS) Appendix H Alphabetic index of performance measures by clinical condition or topic (continued) 35

Appendices Appendix I Appendix J Appendix K Genetic testing modifiers Electrodiagnostic medicine listing of sensory, motor, and mixed nerves Appendix K List of codes pending FDA approval (continued) 36

Appendices Appendix L Appendix M List of vascular families List of deleted CPT codes and descriptions with crosswalk to new CPT codes 37

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 (►◄) There are eight symbols within the CPT book 38

CPT Symbols Semicolon saves space in CPT (;) Plus identifies add-on codes for procedures that are commonly, but not always, performed at the same time and by the same surgeon as the primary procedure (+) 39

CPT Symbols Circle with slash identifies forbidden or prohibited codes exempt from modifier -51 () Bull’s eye identifies a procedure that includes MCS () Flash identifies codes that classify products pending FDA approval () (continued) 40

CPT Symbols Symbol CPT Entry Use of semicolon 11000 Current Procedural Terminology © 2008 American Medical Association. All rights reserved. Symbol CPT Entry Use of semicolon 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface Use of plus symbol + 11001 Each additional 10% of body surface (List separately in addition to code for primary procedure) Use of -51 modifier exemption symbol  17004 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions Use of bull’s eye symbol  33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial 41

CPT Guidelines Define terms and explain assignment of codes for procedure and services Located at beginning of each CPT section Guidelines from one CPT section do not apply to another CPT section Should be reviewed before assigning code

Sections, Subsections, Categories, and Subcategories Six sections are subdivided into: Subsections Categories Subcategories Guidelines at beginning of each subsection Notes, parenthetical notes, and descriptive qualifiers are in each of the Sections, Subsections, Categories, and Subcategories 43

Sections, Subsections, Categories, and Subcategories Selection from CPT that illustrates sections, subsections, categories, subcategories, notes, and descriptive qualifiers Current Procedural Terminology © 2008 American Medical Association. All rights reserved. 44

Unlisted Procedures and Services Unlisted procedure or unlisted service Assigned when provider performs procedure or service for which there is no CPT code Special report must accompany claim to provide more information (e.g., copy of procedure report) 45

Instructional Notes Blocked un-indented note Indented parenthetical note Parenthetical note Blocked un-indented note- Located below the title of a subsection, heading or subheading contains instructions that apply to all codes in the subsection/heading/category/subheading/subcategory Indented parenthetical note- Located below the title of a subsection, heading, and subheading Note applies to only that code unless specified otherwise Parenthetical note Located in the code description to provide examples 46

Descriptive Qualifiers Terms that clarify assignment of CPT code They can occur in the middle of a main clause or after a semicolon and may or may not be enclosed in a parentheses. Make sure you read all descriptions carefully before assigning a code! 47

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 (continued) 48

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 49

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) 50

Greater, Reduced, or Discontinued Services -74 Discontinued outpatient hospital/ ambulatory surgery center procedure after anesthesia administration 51

Global Surgery -54 Surgical care only -55 Postoperative management only -56 Preoperative management only 52

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) 53

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 54

Bilateral and Multiple Procedures -50 Bilateral procedure -27 Multiple outpatient hospital E/M encounters on same date -51 Multiple procedures 55

Repeat Services -76 Repeat procedure by same physician -77 Repeat procedure by another physician 56

Multiple Surgeons -62 Two surgeons -66 Surgical team -80 Assistant surgeon -81 Minimum assistant surgeon -82 Assistant surgeon (when qualified resident not available) 57

Professional and Technical Components -26 Professional component TC Technical component (found in HCPCS level II manual) 58

Mandated Services -32 Mandated services -23 Unusual anesthesia -47 Anesthesia by surgeon 59

Laboratory Services -90 Reference (outside) laboratory -91 Repeat clinical diagnostic laboratory test -92 Alternative laboratory platform testing 60

Multiple Modifiers -99 Multiple modifiers Used to alert third party payer that there are more than four modifiers on the CPT 61

NCCI Promotes national correct coding methodologies Controls improper code assignment Implemented by CMS Edits used to process Medicare Part B claims Medicare part B are outpatient claims 62

NCCI Edits Two types: Comprehensive/Component edits Mutually exclusive edits Comprehensive/Component edits-code pairs that should not be billed together because one service inherently includes the other Mutually exclusive edits-code pairs that , for clinical reasons, are unlikely to be performed on the same patient on the same day, Example two different types of test that yield equivalent results. 63

Advanced Beneficiary Notice (ABN) Form completed and signed by Medicare beneficiary each time provider believes a normally covered service will not be covered and provider wants to bill beneficiary directly for the service 64

Notice of Exclusions from Medicare Benefits (NEMB) Form completed and signed by Medicare beneficiary before items, procedures, and services excluded from Medicare benefits are provided 65

Unbundling Reporting multiple codes for a service when a single, comprehensive code should be assigned 66

Questions