HS 225 Unit 5 Presentation Chapter 23: HCPCS Codes

Overview Healthcare Common Procedure Coding System is referred to using the acronym HCPCS, Two levels HCPCS level I HCPCS level II Healthcare Common Procedure Coding System is referred to using the acronym HCPCS, 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 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) 6

HCPCS Level II National Codes HCPCS National Panel responsible Panel consists of: Blue Cross/Blue Shield Association Health Insurance Association of America CMS 7

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. 8

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. 9

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) 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 Organized by type Permanent national 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 11

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 12

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) 13

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) 14

HCPCS Level II J Codes Permission to reuse in accordance with http://www.cms.hhs.gov Web site Content Reuse Policy. 15

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) 16

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 17

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) 18

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 19

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) 20

Greater, Reduced, or Discontinued Services -74 Discontinued outpatient hospital/ ambulatory surgery center procedure after anesthesia administration 21

Global Surgery -54 Surgical care only -55 Postoperative management only -56 Preoperative management only 22

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) 23

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 24

Bilateral and Multiple Procedures -50 Bilateral procedure -27 Multiple outpatient hospital E/M encounters on same date -51 Multiple procedures 25

Repeat Services -76 Repeat procedure by same physician -77 Repeat procedure by another physician 26

Multiple Surgeons -62 Two surgeons -66 Surgical team -80 Assistant surgeon -81 Minimum assistant surgeon -82 Assistant surgeon (when qualified resident not available) 27

Professional and Technical Components -26 Professional Component -TC Technical Component (found in HCPCS level II manual) 28

Mandated Services -32 Mandated services -23 Unusual anesthesia -47 Anesthesia by surgeon 29

Laboratory Services -90 Reference (outside) laboratory -91 Repeat clinical diagnostic laboratory test -92 Alternative laboratory platform testing 30

Multiple Modifiers -99 Multiple modifiers Used to alert third party payer that there are more than four modifiers on the CPT 31

Questions