B&C Chapter 8: HCPCS Level II Coding

Question 1

certificate of medical necessity (CMN)

Answer 1

prescription document for durable medical equipment, services, and supplies that is signed by the treating physician and submitted with the CMS-1500 claim to the DME MAC for reimbursement

Question 2

CMS HCPCS Workgroup

Answer 2

develop and maintain HCPCS level II; composed of representatives from CMS, Medicaid State agencies, the Veterans Administration, and the Medicare Pricing, Data Analysis and Coding (PDAC) contractors

Question 3

DME MAC

Answer 3

process Medicare durable medical equipment (DME) claims for defined geographic areas

Question 4

durable medical equipment (DME)

Answer 4

defined by Medicare as equipment that can withstand repeated use, is primarily used to serve a medical purpose, is used in the patient’s home, and would not be used in the absence of illness or injury

Question 5

durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)

Answer 5

include artificial limbs, braces, medications, surgical dressings, and wheelchairs.

Question 6

durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) dealers

Answer 6

supply patients with durable medical equipment (DME) (e.g., canes, crutches); submit claims to DME Medicare administrative contractors (MACs) who are awarded contracts by CMS

Question 7

miscellaneous codes

Answer 7

reported when a DMEPOS dealer submits a claim for a product or service for which there is no existing permanent national code.

Question 8

modifiers

Answer 8

provide additional information about a procedure or service (e.g., left-sided procedure)

Question 9

permanent national codes

Answer 9

maintained by the HCPCS National Panel, composed of representatives from the BlueCross BlueShield Association (BCBSA), the Health Insurance Association of America (HIAA), and CMS

Question 10

temporary codes

Answer 10

maintained by the CMS and other members of the HCPCS National Panel; independent of permanent national codes.

Question 11

Medicare Pricing, Data Analysis and Coding (PDAC) contractor

Answer 11

responsible for providing suppliers and manufacturers with assistance in determining HCPCS codes to be used; PDACs replaced SADMERCs (statistical analysis durable medical equipment regional carriers)

Question 12

orthotics

Answer 12

branch of medicine that deals with the design and fitting of orthopedic (relating to bone disorders) devices (e.g., braces)

Question 13

prosthetics

Answer 13

branch of medicine that deals with the design, production, and use of artificial body parts (e.g., artificial limbs)

Question 14

transitional pass-through payments

Answer 14

temporary additional payments (above the OPPS reimbursement rate) made for certain innovative medical devices, drugs, and biologicals provided to Medicare beneficiaries