Level Ii National Codes Are Not Used In Which Setting?

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What is HCPCS?

Healthcare Common Procedure Coding Arrangement (HCPCS) is a standardized lawmaking system necessary for medical providers to submit healthcare claims to Medicare and other health insurances in a consistent and orderly manner. HCPCS comprises two medical lawmaking sets, HCPCS Level I and HCPCS Level 2.

HCPCS Level I consists of the Electric current Procedural Terminology (CPT^®) code set and is used to submit medical claims to payers for procedures and services performed by physicians, nonphysician practitioners, hospitals, laboratories, and outpatient facilities.

HCPCS Level 2 is the national process code set for healthcare practitioners, providers, and medical equipment suppliers when filing wellness plan claims for medical devices, supplies, medications, transportation services, and other items and services.

When medical coders and billers talk about HCPCS codes, they're referring to HCPCS Level II codes. When they talk about CPT^® coding, they're actually referring to HCPCS Level I.

If you lot're new to medical coding or even well practiced in CPT^® and HCPCS Level II reporting, you lot may be asking yourself two questions.

Why are CPT^® codes too called HCPCS Level I codes?
Why are HCPCS Level II codes, which appear to represent everything but routine medical procedures, considered a national procedure code gear up?

To understand the answers to these questions and gain a better grasp of HCPCS coding, y'all need to know how these 2 code sets came into being.

History of HCPCS Coding

The history of HCPCS coding began in 1978 when the federal authorities created this coding system to standardize the reporting of medical services to the federal government for reimbursement. The HCPCS system, however, underwent several changes before adoption by commercial payers, which was eventually mandated by HIPAA in 1996.

Prior to the advent of procedure coding, providers submitted written descriptions of the services they performed to payers for reimbursement. This proved inefficient, in that 100 providers could report the same service with 100 dissimilar descriptions.

The American Medical Association (AMA) was the first to tackle the trouble. In efforts to standardize reporting of medical, surgical, and diagnostic services and procedures, the association created a coding system and introduced CPT^® in 1966.

By this time, the government had become a major payer of healthcare services. While it too needed to standardize healthcare claims, it besides bore the responsibility of controlling costs for taxpayers. With this dual agenda, it created the HCFA Common Procedure Coding System (HCPCS).

In the in a higher place expansion of the HCPCS acronym, notice that the "H" does non stand for Healthcare, as it currently does. That's because the federal agency we know today every bit the Centers for Medicare & Medicaid Services (CMS) went by the name of the Wellness Intendance Financing Administration (HCFA) until June 14, 2001. The original code set it created—essentially a version of CPT^® tailored for claims filed with the government—was self-named.

But standardization in medical reporting was not nevertheless achieved. In the subsequent decade, more 120 different coding systems came into play, causing widespread variations in payers' guidelines and claim forms.

In 1983, CMS merged its HCFA Mutual Procedure Coding Organisation with AMA'due south CPT^® and mandated apply of CPT^® for all Medicare billing.

Meanwhile, these two organizations had been collaborating on the evolution of a new code set to study medical-related expenses not represented in CPT^® - items such as orthotic and prosthetic procedures, hearing and vision services, ambulance services, medical and surgical supplies, drugs, nutrition therapy, durable medical equipment, outpatient hospital care, and Medicaid.

The resulting code ready, also implemented in 1983, begins where CPT^® ends. As such, it is the second of two principal subsystems of HCPCS, aptly named HCPCS Level II.

And so it is, through the development of HCPCS coding, that CPT^® was incorporated as the backbone of Level I, and the newer HCPCS Level 2 became known as a procedure coding system. Though procedures are only a small-scale part of the HCPCS Level II lawmaking set, most HCPCS codes are linked in application to process codes, as you lot will see.

History of HCPCS

Figure 1: Development of procedure coding systems. (Modified from Fordney MT, French LL: Medical Insurance Billing and Coding, ed 1, St Louis, 2003, Saunders.)

In the timeline higher up, note the relatively short-lived advent of HCPCS Level III codes. The utilize of HCPCS Level III Local Regional codes for specific programs and jurisdictions was discontinued in 2003 to promote consistent coding standards.

Besides in the timeline, discover that when HCFA became CMS in 2001, the HCPCS name inverse to Healthcare Common Procedure Coding Organisation.

HCPCS At A Glance

Among medical lawmaking sets—ICD-10, CPT^®, and HCPCS Level Two—HCPCS Level II is the almost dynamic. CMS updates HCPCS Level Ii codes throughout the year, based on factors that include public input and feedback from providers, manufacturers, vendors, specialty societies, Blue Cross, and others.

Farther distinctions between CPT^® codes (HCPCS Level I) and HCPCS Level II codes include:

Code Set	Codes Uses	Code Construction	Maintaining Body	Menstruum in Utilise	Frequency of Updates
HCPCS Level I: Current Procedural Terminology, Fourth Edition	Procedures and services provided past physicians and other centrolineal healthcare professionals	5 numeric characters; some codes with a fifth alpha character	AMA	1966 to nowadays	Yearly, in late summer or early fall for Jan. i implementation; some codes updated on January. one and July 1 for use six months later on
HCPCS Level 2: National Healthcare Common Procedure Coding System	Drugs, supplies, equipment, non-doc services and services non represented in CPT^®	v characters, start with a letter and followed by 4 numbers	CMS	1983 to present	Yearly updates of the permanent lawmaking prepare, with quarterly updates of temporary codes

Construction of Level Ii HCPCS Codes

All HCPCS Level Ii codes consist of five characters, commencement with a letter of the alphabet—A through Five—and followed by iv numeric digits. The alphabetic character that begins the HCPCS Level Two code represents the code affiliate to which the HCPCS code belongs, thereby grouping like items together.

Some examples of HCPCS Level II codes include:

J9355 — Injection, trastuzumab, excludes biosimilar, 10 mg
G9631 — Patient sustained ureter injury at the fourth dimension of surgery or discovered subsequently up to 30 days mail-surgery
C1823 — Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads
V2599 — Contact lens, other type

The codes in each HCPCS lawmaking range are categorically referred to by the letter they begin with. For case, codes kickoff with the letter of the alphabet J—used to report non-orally administered medication and chemotherapy drugs—are called J codes. Incidentally, J codes are amongst the nigh unremarkably reported codes in the HCPCS Level Two code set.

HCPCS CODES RANGE

A0021-A0999
Ambulance and Other Transport Services and Supplies
A4206-A8004
Medical And Surgical Suppliess
A9150-A9999
Administrative, Miscellaneous and Investigational
B4034-B9999
Enteral and Parenteral Therapy
C1713-C9899
Outpatient PPS
E0100-E8002
Durable Medical Equipment
G0008-G9987
Procedures / Professional person Services
H0001-H2037
Alcohol and Drug Abuse Handling
J0120-J8999
Drugs Administered Other than Oral Method
J9000-J9999
Chemotherapy Drugs
K0001-K0900
Durable medical equipment (DME) Medicare administrative contractors (MACs)
L0112-L4631
Orthotic Procedures and services
L5000-L9900
Prosthetic Procedures
M0075-M0301
Miscellaneous Medical Services
M1000-M1071
Screening Procedures
P2028-P9615
Pathology and Laboratory Services
Q0035-Q9995
Temporary Codes
R0070-R0076
Diagnostic Radiology Services
S0012-S9999
Temporary National Codes (Not-Medicare)
T1000-T5999
National Codes Established for State Medicaid Agencies
V2020-V2799
Vision Services
V5008-V5364
Hearing Services
Come across the consummate level 2 HCPCS lawmaking list

How HCPCS Level II Codes Are Used

HCPCS Level II codes report what a provider used during a service provided to a patient to treat or appraise a given diagnosis. As such, HCPCS codes are used in conjunction with CPT^® and ICD-10 codes, as these three code sets are interdependent and come together in medical coding and billing, often in a single claim.

For a provider to receive reimbursement for a medical service, represented past a CPT^® lawmaking, the medical coder must submit an ICD-x code depicting the patient'due south diagnosis to demonstrate medical necessity for the service. A HCPCS code is then added to the merits (when required by the payer) to report products that may have been prescribed, injected, or otherwise delivered to the patient during the service.

In full general terms—with some exceptions—medical coders use the three code sets when submitting medical claims to report the following:

CPT^® codes: what the provider did.
HCPCS codes: what the provider used.
ICD-10-CM: why the provider 'did' and 'used'.

For example, if a urologist diagnoses a patient with bladder cancer and performs a float instillation of i mg of Bacillus Calmette-Guerin (BCG) to care for the tumor, the medical coder might assign:

CPT^® codes (did): 51720 (Float instillation of anticarcinogenic agent (including retention time))
HCPCS code (used): J9030 (BCG live intravesical instillation, 1mg)
ICD-10 code (why): C67.9 (Malignant neoplasm of bladder, unspecified)

Equally mentioned in a higher place, though, there are some exceptions to these general code gear up concepts.

WHEN TO Cull CPT^® Vs HCPCS

First, non all payers have HCPCS Level Ii codes. Initially intended for Medicare claims, many individual payers have since adopted the HCPCS Level II code gear up. In fact, under the HIPAA requirement for standardized coding systems, HCPCS level 2 was selected for describing healthcare equipment and supplies not represented in CPT^® due to its widespread commercial acceptance. That said, the existence of a HCPCS Level II code does not point third-party coverage. The medical coder must verify coverage with the payer prior to submitting a claim.

A 2d exception that may influence whether to choose a CPT^® lawmaking or a HCPCS Level Two code comes into play when the HCPCS lawmaking represents a procedure (what the provider did).

When a CPT^® code and HCPCS Level 2 code exist for the aforementioned service or procedure, Medicare frequently requires you to report the HCPCS Level II code. Several third-political party payers follow Medicare guidelines, but you must check with your payer.

You lot must likewise study the stardom between similar CPT^® and HCPCS Level 2 lawmaking options. For instance, HCPCS Level II list various G codes to report screening services. The operative word in each of these HCPCS Yard code descriptors is screening.

Screening procedures are non diagnostic procedures. In other words, the HCPCS screening codes utilize simply to asymptomatic patients. Consider the following HCPCS code examples:

You might submit HCPCS lawmaking G0121 (Colorectal cancer screening; barium enema) when an asymptomatic patient fits the in one case every 10-twelvemonth interval. If you lot bill G0121 earlier than the 10-year period, your merits will likely be denied.

But if a patient complains of symptoms such equally blood in stool, and the gastroenterologist performs a diagnostic colonoscopy, you would choose CPT^® code 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] past brushing or washing, when performed [separate procedure]).

Similarly, if an aberrant finding prompts your physician to convert a colorectal cancer screening into a diagnostic procedure, you would abandon the HCPCS code for the advisable CPT^® code and suspend it with CPT^® modifier PT (Colorectal cancer screening examination; converted to diagnostic test or other procedure).

Other circumstances may involve the pick of reporting a HCPCS Level II lawmaking if the HCPCS lawmaking offers greater specificity than the CPT^® code. This is sometimes the case with CPT^® codes that stand for supplies.

For instance, you lot would choose CPT^® lawmaking 29540 (Strapping; ankle and/or foot) to report the service of a physician who diagnosed a sprained correct ankle and applied layers of web curl followed past adhesive record to stabilize the patient'southward ankle, which he and then covered with the application of an rubberband bandage.

If this encounter was an initial service with "no other process or treatment" required, you would also report CPT^® code 99070 to document the use of supplies like record or bandages. Some coders, though, opt to forgo the generic CPT® lawmaking 99070, preferring instead the detailed HCPCS A code options, such as A6448 (Low-cal compression bandage, elastic, knitted/woven, width less than 3 inches, per thou).

HCPCS Level Two Modifiers

HCPCS modifiers consist of two alpha or alphanumeric characters and are appended with a hyphen to the cease of a HCPCS (or CPT^®) code to expand the clarification of the code. Medical coders use HCPCS Level 2 modifiers when the data provided by a HCPCS code descriptor needs supplementation to fully capture the circumstances that utilize to an item or service.

For instance, you would use the HCPCS modifier UE when an particular identified by a HCPCS code is "used equipment." The NU modifier would be added to indicate "new equipment."

Then, if you lot're filing a claim for a patient who was prescribed and received a new wheelchair, you might study HCPCS code E1130 (Standard wheelchair, fixed full-length arms, stock-still or swing away, detachable footrests) and append NU, equally in E1130-NU, which would significantly touch reimbursement.

Another HCPCS lawmaking example demonstrates how modifiers affect reimbursement past bookkeeping for loss.

If your provider administers 44 units of Botulinum toxin injection by direct laryngoscopy from a 100-unit single-dose vial, and and so had to discard the remaining contents of the vial, you could report the discarded drug with the HCPCS JW modifier.

For this scenario, y'all'd report HCPCS lawmaking J0585 (Injection, onabotulinumtoxinA, 1 unit) on ii divide lines. On the first line, y'all'd report J0585 x 44 to identify the amount administered. On the 2d line you would report J0585-JW x 56 to identify the corporeality discarded.

When reporting codes with more than one modifier, always list functional or pricing modifiers in the first position. Payers consider functional modifiers when determining reimbursement. Next, report the informational modifiers.

Yous will notice the complete list of HCPCS Level II modifiers and their descriptions in the appendix of most HCPCS Level 2 lawmaking books.

Keeping Footstep with HCPCS Level II

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires CMS to review HCPCS Level Ii codes for potential changes that would raise accurate reporting and billing for medical items and services. This involves maintaining HCPCS Level II quarterly updates, releasing information, and posting transaction and lawmaking set standards on its website.

Providers may acquire the CMS HCPCS Level II awarding form and instructions for submitting a recommendation to found, revise, or discontinue a code.

Various types of HCPCS Level II codes are defined co-ordinate to their purpose and who is responsible for establishing and maintaining them:

Permanent national HCPCS Level II codes
Dental codes
Miscellaneous codes (not otherwise classified)
Temporary national codes

Permanent national HCPCS Level II codes are updated annually past CMS. The CMS HCPCS Workgroup meets monthly to discuss if requests warrant a change to the national permanent codes. CMS and so bug preliminary decisions for public comment and holds public meetings before making last decisions on codes.

Dental codes are a separate category of national codes for billing dental procedures and supplies. The American Dental Clan (ADA) created the Current Dental Terminology (CDT®) code set comprised of HCPCS dental service codes, which are likewise called D codes considering these codes begin with the letter of the alphabet D. The ADA holds the copyright to CDT codes and makes all decisions regarding the revision, deletion, or addition of dental service codes.

Miscellaneous codes (non otherwise classified) are used when no national code describing an item or service exists. A miscellaneous code maybe assigned past insurers for use while CMS considers the request for a new code. HCPCS miscellaneous codes also let suppliers to bill for items or services as they are FDA-approved.

Before submitting a miscellaneous code, you should check with the health plan to verify the absence of a specific code. When submitting a claim to Medicare, it may be beneficial to contact your Medicare representative for coding communication.

Temporary national codes are used at the discretion of CMS to run into specific operating needs, such equally newly issued coverage policies or legislative requirements. HCPCS temporary codes allow health plans to establish codes prior to the almanac update on January. i.

Temporary codes tin can be added, inverse, or deleted on a quarterly footing—though they do non have established expiration dates. If CMS decides to replace a HCPCS Level II temporary code with a permanent national lawmaking, the temporary code is deleted and cross-referenced to the new permanent code.

Newly established temporary codes effective dates are posted on the HCPCS Level Ii website.

TYPES OF TEMPORARY HCPCS LEVEL Ii CODES

1. C codes are required under the Medicare Outpatient Prospective Payment System (OPPS) for use by hospitals to report drugs, biologicals, magnetic resonance angiography (MRA), and devices. Other facilities may report C codes at their discretion.

2. G codes are national codes assigned past CMS to identify professional healthcare procedures and services that may not have assigned CPT^® codes.

3. H codes constitute unique HCPCS temporary codes to identify mental health services for country Medicaid agencies mandated past state law to constitute separate codes for those services.

4. K codes are used by Durable Medical Equipment Medicare Administrative Contractors (DME MACs). DME MACs develop new K codes when existing national codes for supplies and certain product categories do non include the codes needed to implement a DME MAC medical review policy.

5. Q codes place services that would non be given a CPT® code or are non identified by national Level II HCPCS codes but are needed past CMS to facilitate claims processing. Such services include drugs, biologicals, and other types of medical equipment or services.

half dozen. S codes meet various business organization needs of commercial and Medicaid agency health plans. HCPCS Due south codes written report drugs, services, and supplies for which national codes do not be but are needed to implement policies, programs, or support claims processing. They are not payable by Medicare.

vii. T codes are designated for employ past Medicaid agencies to establish codes for items for which there are no permanent national codes, and for which codes are necessary to see Medicaid program operating needs. T codes are not used by Medicare merely may be used by commercial health plans.

Interested in Condign a Medical Coder?

If y'all've been thinking about a career in medical coding, in that location has never been a better time. Not only are medical coders in short supply and loftier need, only training to go a Certified Professional Coder (CPC^®) is far more than affordable than college—and doesn't accept a fraction of the time. Learn proficient use of ICD-x, CPT^®, and HCPCS, and launch your new career on the business side of healthcare.

And in the meantime, if y'all have HCPCS coding questions that nosotros haven't answered, yous can postal service them hither and receive helpful insight from AAPC members working in diverse healthcare settings.

Last Reviewed on Oct 24, 2019 by AAPC Thought Leadership Team

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