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

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

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

4. 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)

5. 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

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

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

8. 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)

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

10. 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

11. HCPCS Level II Table of Drugs
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12. HCPCS Level II Organized by type Permanent national codes
Dental codes (D0000-D9999)
Miscellaneous codes
Temporary codes
Modifiers
(continued)

13. 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)

14. 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)

15. 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

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

17. Partial List of HCPCS Level II Modifiers
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18. HCPCS Level II Modifiers Index Code sections
Administrative, miscellaneous, and investigational
Outpatient Prospective Payment System (PPS)

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

21. 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)

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

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

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

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

27. 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)

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

29. Advance Beneficiary Notice
Waiver signed by patient
(continued)

30. 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

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