Correct Healthcare Common Procedure Coding System (HCPCS) code selection is an essential element for claims payment. Choosing correct HCPCS code is an essential for accurate insurance reimbursements. On the other hand, incorrect coding may result in improper payment necessitating recoupment and possible false claim actions. It is important that all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers take steps to ensure that claims are correctly coded. Each payer separately develops their own coverage criteria, coding guidelines, and fees for HCPCS Level II codes.
Background of HCPCS Code
The HCPCS is a standardized set of codes used for billing items and services to all payers, including Medicare and Medicaid. The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS.
- The HCPCS is divided into two principal subsystems, referred to as level I and level II. Level I of the HCPCS is comprised of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services, dental services, and procedures furnished by physicians and other healthcare professionals.
- Level I of the HCPCS is comprised of Current Procedural Terminology (CPT-4), a numeric coding system maintained by the American Medical Association (AMA). The CPT-4 is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals. These healthcare professionals use the CPT-4 to identify services and procedures for which they bill public or private health insurance programs. Level I of the HCPCS, the CPT-4 codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.
- Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and DMEPOS when used outside a physician’s office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes were established for submitting claims for these items.
Choosing the Correct HCPCS Code
Each supplier is responsible for the HCPCS code(s) they select to bill for the items provided. Here are some tips that will help:
- Always refer to the ‘long’ code narrative. All codes have short and long descriptors. The long descriptor often provides more detail regarding the requirements for the code. Select the code with the descriptor that most closely describes the product.
- Suppliers should check with the pricing, coding analysis, and coding (PDAC), contractor to CMS. The PDAC is responsible for providing suppliers and manufacturers with assistance in determining which HCPCS code should be used to describe DMEPOS items for the purpose of billing Medicare.
- You can check Medicare Administrative Contractor (MAC) publications for coding bulletins and coding guidelines related to products and HCPCS codes for specific information on the item of interest.
- Most code narratives are written broadly to be all-inclusive. You may not find a specific code that perfectly matches a product. Use the code that most closely describes the item rather than a NOC (not otherwise classified) or miscellaneous code.
- Local Coverage Determination (LCD) related policy articles often have additional information in the coding guidelines section. Coding guidelines provide additional information on the characteristics of products that meet a specific HCPCS code.
- Note that the price and fees are not part of the correct coding. Selecting a code based upon the fee schedule may result in an incorrect coding determination. HCPCS codes describe the product, not the price.
- Correct coding is an essential element for correct claim payment. The insurance carrier maintains a variety of resources to assist suppliers in determining the appropriate code.
Medisys Data Solutions is a leading medical billing company providing complete billing and coding services for various medical billing specialties. We shared basic information on choosing correct HCPCS code for provider reference purposes. For a detailed understanding, you can check the following reference links. If you are seeking assistance in coding for your practice, contact us at info@medisysdata.com / 888-720-8884
Reference: HCPCS Coding Questions
