HCPCS Level II National Coding System Overview

1. Chapter 7 HCPCS Level II NationalCoding 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 Permission to reuse in accordance with http://www.cms.hhs.gov website Content Reuse Policy.

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 Permission to reuse in accordance with http://www.cms.hhs.gov website Content Reuse Policy.

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

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

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 Permission to reuse in accordance with http://www.cms.hhs.gov website Content Reuse Policy.

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