HCPCS Level II National Coding System Chapter 7 HCPCS Level II National Coding System

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

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

HCPCS Level II HCPCS national codes and two-character modifiers Describe common medical services and supplies not classified in CPT Five characters in length Begins with letters A-V, followed by four numbers e.g., abdominal aneurysm wrap (M0301)

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 absence of illness or injury

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

HCPCS Level II National Codes Classify similar medical products and services for claims processing (continued)

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

HCPCS Level II National Codes HCPCS National Panel responsible Panel consists of: Blue Cross/Blue Shield Association Health Insurance Association of America CMS

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

HCPCS Level II Table of Drugs Permission to reuse in accordance with http://www.cms.hhs.gov website Content Reuse Policy.

HCPCS Level II Organized by type Permanent national codes Dental codes (D0000-D9999) Miscellaneous codes Temporary codes Modifiers (continued)

HCPCS Level II Temporary Code Categories C codes Outpatient procedures and services G codes Professional health care procedures that do not have codes identified in CPT H codes Mental health services (continued)

HCPCS Level II Temporary Code Categories K codes When permanent national codes do not include codes needed to implement medical review coverage policy Q codes Services that would not ordinarily be assigned a CPT code (continued)

HCPCS Level II Temporary Code Categories S codes No HCPCS level II national codes exist to report drugs, services, and supplies T codes No HCPCS level II permanent codes exist, but codes needed to administer Medicaid

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

Partial List of HCPCS Level II Modifiers Permission to reuse in accordance with http://www.cms.hhs.gov website Content Reuse Policy.

HCPCS Level II Modifiers Index Code sections Administrative, miscellaneous, and investigational Outpatient Prospective Payment System (PPS)

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

HCPCS Level II C codes Dental procedures (D0000-D9999) DME (E0100-E9999) Procedures/professional services (G0000-G9999) Temporary (continued)

HCPCS Level II Alcohol and/or drug abuse treatment services (H0001-H2037) Drugs administered other than oral method (J0000-J9999) Temporary codes (K0000-K9999) Orthotic procedures (L0000-L4999) (continued)

HCPCS Level II Prosthetic procedures (L5000-L9999) Medical services (M0000-M0301) Pathology and laboratory services (P0000-P9999)

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

HCPCS Level II Q codes (Q0035-Q9968) Temporary Diagnostic radiology services (R0000-R5999) Temporary national codes (non-Medicare) (S0000-S9999) (continued)

HCPCS Level II National T codes established for state Medicaid agencies (T1000-T9999) Vision services (V0000-V2999) Hearing services (V5000-V5999)

Determining Payer Responsibility Specific code determines where claim sent Medical administrative contractor (MAC) DME MAC Annual list of billing codes and billing instructions

Patient Record Documentation Justifies medical necessity of procedures, services, and supplies coded and reported Documentation should include the following: Patient history Including review of systems (ROS) Physical examination (continued)

Patient Record Documentation Documentation should include the following: Diagnostic test results Diagnoses Duration Comorbidity Prognosis

Advance Beneficiary Notice Waiver signed by patient (continued)

Advance Beneficiary Notice Acknowledges that, since medical necessity for procedure, service, or supply cannot be established, patient accepts responsibility for reimbursing provider or DME, prosthetic, orthotic and supplies (DMEPOS) dealer for costs associated with procedure, service, or supply

DMEPOS Claims Certificate of medical necessity Prescription for DME, services, and supplies DME MAC medical review policies Include local and national coverage determinations