Transcript Document

Chapter 7
HCPCS Level II
National Coding
System
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Overview
• Three levels
– HCPCS level I
– HCPCS level II
– HCPCS level III
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HCPCS Level I
• Five-digit CPT codes and two-digit
modifiers
• Developed by American Medical
Association (AMA)
• Updated annually
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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)
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Durable Medical Equipment (DME)
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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
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HCPCS Level III
• Effective December 31, 2003, HCPCS level
III local codes are no longer reported.
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HCPCS Level II National Codes
• Classify similar medical products and
services for claims processing
• Each code contains a description:
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DME
Medications
Provider services
Temporary Medicare codes (e.g., Q codes)
Other items and services (e.g., ambulance)
(continued)
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HCPCS Level II National Codes
• HCPCS National Panel responsible
• Panel consists of:
– Blue Cross/Blue Shield Association
– Health Insurance Association of America
– CMS
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Common HCPCS Level II References
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General guidelines and instructions
Appendix (e.g., additions, deletions)
Table of drugs or deleted codes
Symbols
Special coverage instructions
Current national modifiers
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HCPCS Level II Table of Drugs
Permission to
reuse in
accordance with
http://www.cms.hhs.
gov Web site
Content Reuse
Policy.
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HCPCS Level II
• Organized by type
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Permanent national codes
Dental codes
Miscellaneous codes
Temporary codes
Modifiers
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(continued)
HCPCS Level II
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Permanent national codes
Dental codes (D0000–D9999)
Miscellaneous codes
Temporary codes
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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
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(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
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(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
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HCPCS Level II Modifiers
• Attached to any HCPCS level I or II code
• Provide additional information
• Not all codes require modifiers
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Permission to
reuse in
accordance with
Partial List of HCPCS
Level II Modifiers
http://www.cms.hhs.
gov Web site
Content Reuse
Policy.
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HCPCS Level II
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Modifiers
Index
Code sections
Administrative, miscellaneous, and
investigational
• Outpatient Prospective Payment System
(PPS)
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HCPCS Level II Index Entries
Permission to
reuse in
accordance with
http://www.cms.hhs.
gov Web site
Content Reuse
Policy.
© 2010 Delmar, Cengage Learning
HCPCS Level II
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C codes
Dental procedures
DME
Procedures/Professional Services
(Temporary) (G0000–G9999)
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(continued)
HCPCS Level II
• Alcohol and/or Drug Abuse Treatment
Services (H0001–H2037)
• Drugs Administered other than Oral Method
(J0000–J9999)
• Temporary codes
• Orthotic Procedures (L0000–L4999)
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(continued)
HCPCS Level II
• Prosthetic Procedures (L5000–L9999)
• Medical Services (M0000–M0301)
• Pathology and Laboratory Services (P0000–
P9999)
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HCPCS Level II J Codes
Permission to
reuse in
accordance with
http://www.cms.hhs.
gov Web site
Content Reuse
Policy.
© 2010 Delmar, Cengage Learning
HCPCS Level II
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Q codes (temporary) (Q0000–Q9999)
Diagnostic radiology services (R0000–R5999)
Temporary national codes (non-Medicare)
National T codes established for state
Medicaid agencies (T1000–T9999)
• Vision services
• Hearing services
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Determining Payer Responsibility
• Specific code determines where claim is sent
– Medical administrative contractor (MAC)
– DME Medicare administrative contractor (MAC)
• Annual list of billing codes and billing
instructions
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Patient Record Documentation
• Justifies medical necessity of procedures,
services, and supplies coded and reported
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(continued)
Patient Record Documentation
• Documentation should include:
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Patient history, including review of systems (ROS)
Physical examination
Diagnostic test results
Diagnoses (duration and comorbidity)
Prognosis
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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
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DMEPOS Claims
• Certificate of medical necessity
– Prescription for DME, services, and supplies
• DME MAC medical review policies
– Include local and national coverage determinations
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