Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education Chapter 13 HCPCS Level II Coding: Introduction and Guidelines

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives LO 13.1 Identify the scope of categories reported with HCPCS Level II codes. LO 13.2 Correctly use the alphabetic index within HCPCS Level II codes. LO 13.3 Confirm codes suggested by the index in the alphanumeric listing. 13-2

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives (cont.) LO 13.4 Interpret the meanings of the notations and symbols. LO 13.5 Apply the additional information provided by the appendixes. 13-3

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Chelation therapy Durable medical equipment (DME) Durable medical equipment regional carrier (DMERC) Enteral 13-4

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Not otherwise specified (NOS) Orthotic Parenteral Prosthetic 13-5

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction Healthcare Common Procedure Coding System Level I = CPT codes Level II = HCPCS codes 13-6

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. HCPCS Level II Categories Used to report a service, a procedure, and supplies that are not properly described in the CPT book –Five characters One letter Four numbers 13-7

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. HCPCS Level II Categories (cont.) Report the provision of –Durable medical equipment –Pharmaceuticals administered by a health care professional –Medical supplies provided for the patient’s own use 13-8

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. HCPCS Level II Categories (cont.) Report the provision of –Dental services –Transportation services –Vision and hearing services –Orthotic and prosthetic procedures 13-9

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. HCPCS Level II Categories (cont.) Medicare and Medicaid approved Some private third-party payers accept HCPCS Level II codes Coder responsible for determining whether each third-party payer accepts HCPCS Level II codes 13-10

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphabetic Index Lists the Level II code descriptions in alphabetic order from A to Z –Brand name of drug –Generic name of drug –Medical supply item 13-11

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphabetic Index (cont.) Lists the Level II code descriptions in alphabetic order from A to Z –Orthotic –Prosthetic –Service –Surgical supply 13-12

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphabetic Index (cont.) Includes many alternate terms identified by notations in the alphanumeric listings Listed in sections 13-13

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphabetic Index (cont.) Grouped by –Type of service –Type of supply item –Type of equipment they represent 13-14

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview Presents codes in alphabetic order by the first letter and then numerical order beginning with the first number of that code 13-15

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) A0000–A0999 Transportation Services Including Ambulance A4000–A8999 Medical Supplies –Medical supplies, surgical supplies, and durable medical equipment (DME) 13-16

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) A9000–A9999 Administrative, Miscellaneous, and Investigational –Nonprescription drugs –Exercise equipment –Non-covered items and services 13-17

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) B4000–B9999 Enteral-Parenteral Therapy –Supplies, formulas, nutritional solutions, infusion pumps C1000–C9999 Outpatient PPS –Drugs, biologicals, devices for transitional pass-through payments 13-18

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) D0000–D9999 Dental Procedures –Current Dental Terminology (CDT) by American Dental Association –Dental services E0100–E9999 Durable Medical Equipment 13-19

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) G0000–G9999 Procedures/Professional Services (Temporary) –Services and procedures without accurate code description in main portion of CPT book 13-20

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) H0001–H2037 Alcohol and Drug Abuse Treatment Services J0000–J9999 Drugs Administered Other Than Oral Method 13-21

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) K0000–K9999 Temporary Codes –For durable medical equipment regional carriers (DMERCs) that are not identified by other codes 13-22

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) L0000–L4999 Orthotic Procedures and L5000–L9999 Prosthetic Procedures –Orthotic devices, orthopedic shoes, prosthetic devices, prosthetic implants, and scoliosis equipment M0000–M0301 Medical Services –Cellular therapy, prolotheraphy, intragastric hypothermia, intravenous chelation therapy 13-23

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) P0000–P9999 Pathology and Laboratory –Includes codes for services not listed in the CPT book Q0035–Q9968 Q Codes (Temporary) –Replace less specific codes for casting and splinting supplies 13-24

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) R0000–R5999 Diagnostic Radiology Services –Report the hauling of portable radiologic equipment 13-25

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) S0000–S9999 Temporary National Codes (Non-Medicare) –Developed by Health Insurance Association of America (HIAA) and Blue Cross Blue Shield Association (BCBSA) –Covers supplies, services, and drugs without other codes 13-26

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) T1000–T9999 National T Codes Established for State Medicaid Agencies –Report services not otherwise described by any other code –Nursing facility and home health–related services, substance abuse treatment, and training-related procedures 13-27

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. The Alphanumeric Listing Overview (cont.) V0000–V2999 Vision Services –If not represented by any other codes –Contact lenses, intraocular lenses V5000–V5999 Hearing Services –Hearing and speech-language pathology 13-28

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations A large bullet indicates a new code A solid triangle indicates a revised code An open circle indicates a reinstated code 13-29

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.)  An open circle with a line indicates code is not covered under the skilled nursing facility prospective payment system  A check mark inside a square box indicates that the code description includes a specific quantity of material or supply 13-30

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) ♂ Used to identify procedures, services and equipment that can only be performed or used on a male patient ♀Used to identify procedures, services, and equipment that can only be performed or used on a female patient 13-31

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) A Used to identify procedures, services, and equipment that are performed or used on a patient of a certain age group M Used to identify procedures, services, and equipment that are performed on pregnant females 12–55 years of age 13-32

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) Z1111 A line through the center of a code indicates a deleted code that may not be used 13-33

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) Notations Used as a guide for the proper use of HCPCS Level II codes –Always Report Concurrent to the xxx Procedure »Include at least one other code when reporting this code –See Also Code Z1111 »Cross-references this code with another that may be similar in description 13-34

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) Notations (cont.) –Clarifications of Coverage Directs to use or not use a code –Report in Addition to Code Z1111 Include another code when reporting this code –See Code Z1111 Directs you to another similar code that is still active 13-35

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) Notations (cont.) –See Code(s): Directs to another, possibly more specific code –Determine If an Alternative HCPCS Level II or a CPT Code Better Describes… Directs to first search for a better code before choosing this code –Use This Code For… Provides alternate terms and/or names included in the scope of this code description 13-36

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) Notations (cont.) –Pertinent Documentation to Evaluate Medical Appropriateness Should Be… Suggests that supplemental documentation be included with the use of this claim 13-37

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) Notations (cont.) –Do Not Use This Code to Report… Warns of circumstances when you are not permitted to use a code 13-38

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Symbols and Notations (cont.) Notations (cont.) –Medicare Covers… Provide additional information about Medicare coverage on the federal level –Code with Caution Warns that the code should be used very carefully, with great assurance that it is the most specific Double-check provider’s notes 13-39

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Appendixes –Appendix 1: Table of Drugs –Appendix 2: Modifiers –Appendix 3: Abbreviations and Acronyms 13-40

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Appendixes (cont.) –Appendix 4: PUB100 References –Appendix 5: New, Changed, Deleted, and Reinstated HCPCS Codes –Appendix 6: Place of Service and Type of Service Codes Content may vary depending upon the publisher of the HCPCS Level II book 13-41

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary HCPCS Level II codes are updated quarterly and are officially effective January 1 of each year, with no grace period The existence of a code does not imply coverage under any given payment plan 13-42