Chapter 6 Flashcards
HCPCS Level 11 Concepts
Healthcare Common Procedural Coding System
*CMS created a three-level coding system in 1983.
*To cover a variety of services, supplies, equipment NOT identified by CPT codes.
*Maintained by
1. CMS
2. HIAA Health Ins Asso of America
3. BC/BS
HCPCs Level 11 Updates Website Quarterly
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.html.
A Codes G Codes
B Codes H Codes
C Codes J Codes
E Codes K Codes
L Codes R Codes
M Codes S Codes
P Codes T Codes
Q Codes V Codes
A Codes
*Transporation
*Medical/surgical supplies
*Administration
B Codes
Enteral and parenteral therapy
C Codes
Pass-through items
E Codes
durable medical equipment
G Codes
Procedures/professional services
H Codes
Alcohol and drug abuse treat
J Codes
Drug administration than oral method/chemotherapy dugs
K Codes
DME supplies
L Codes
Orthotic/prosthetic procedures
M Codes
Medical services
P Codes
Lab/Pathology
Q Codes
Temporary codes
R Codes
Diagnostic Radiology
S Codes
Temporary national codes
(non-Medicare)
T Codes
National codes for state Medicaid agencies
V Codes
Vision/hearing services.
HCPCS Level 11
used for services NOT included in in CPT codes … such as
Ambulance Services and
DMEPOS
(Durable Medical Equipment Prosthetics Orthotics Supplies)
HCPCS Level 111
referred as local codes
To identify a service, for which there is no Level 1 or Level 11 Code, rather than using miscellaneous or NOC (not otherwise classified)
HCPCS Level 11 Format
A red dot = New Procedure Code
A blue triangle = Code Revision
Color Coded Symbols -
Represents Medicare coverage and payment authority for each item or service.
AI = Alphabetic order
TI = Alphanumeric sections full HCPCS code description
HCPCs Level 11 Format Appendices
*Level 11 Modifiers
*Table of Drugs & Biologicals
*Medicare References
*Abb & Acronyms
*Place of Service Codes
(two-digit code to indicate where service was provided)
Look at this in the future… for coding practice.
aapc.com/praticode
Table of Drugs
(C, J, K Q, and S codes)
Table of Drugs ..
when looking in the index under the ter Drugs …
the coder is directed to see also Table of Drugs
Table of Drugs
are based on
*method of administration
*delivery system
*specific to chemotherapy
When looking for specific codes
the index directs the coder to a code, which should be verified in the alphanumeric section
Other info pertaining to HCPCS 11
includes national coverage policy summaries. They indicate circumstances in which items or services are covered.
these policies should be applied when filing Medicare and other govmnt programs.
see the web site on next card
Policies website portal.
these files contain the Level 11 Alphanumeric HCPCS procedure and modifier codes, long and short descriptions and Medicare admin coverage and pricing.
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html
MED: Medicare Exclusion Database
CMS Publication of 100 - IOMs: Internet Only Manual references to the NCDs: National Coverage Determinations
https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/MED_UserManual_Final_V10_05202011.pdf.
HCPCS Level 11 codes
created by CMS to report
*supplies
*materials
*injections
*procedures
*services not defined in CPT code book
When a PCT and HCPCS Level 11 code exist for the same service
*Check w/ payer
*MCR requires HCPCS Level 11
There can be more than one main entry term to locate a code in the HCPCS Level 11
Example
*Shoes/Arch support
or
*Orthopedic shoes/arch support
Route (Method of Administration)
how the drug or biological is administered.
IA - Intra Arterial
IV - Intravenous
IM
IT
SC
Intramuscular
Intrathecal - subdural (spinal)
Subcutaneous (under skin)
INH
VAR
OTH
Inhaled solution
Various routes (joint, cavities, tissue, topical)
Other routes (suppositories, catheter injections)
ORAL
HCPCS Level 11 Code
by mouth
The code to use to report the drug or biological.
Section Review 6.1
What abbreviation is used for a drug or biological given into the subdural space of the spinal cord?
IT
Review 6.1
When 8 mg of Dilaudid are given intravenously, how many units are reported?
Answer: B. 2
Rationale: Look in the Table of Drugs and Biologicals for Dilaudid® which is up to 4 mg given SC, IM, or IV and the table refers you to J1170. J1170 is for 4 mg per unit, so 2 units are reported. Verify code selection the tabular section of the HCPCS Level II code book.
What is the correct code and units to report for 80 mg of Depo-Medrol given IM?
Answer: D. J1040 x 1
Rationale: Look in the Table of Drugs and Biologicals for Depo-Medrol®. There are three entries for the amount given. 80mg given IM is reported with J1040. Because the unit per is 80 mg, only one unit is reported. Verify code selection the tabular section of the HCPCS Level II code book.
What are C codes used for in the HCPCS Level II code book?
Answer: D. Reporting outpatient services by hospitals paid under the OPPS
Rationale: At the beginning of the C section, the subheading indicates Outpatient PPS (C1713-C9899). C codes are used on Medicare Ambulatory Surgical Center (ACS) and Hospital Outpatient Prospective Payment System (OPPS) claims.
What codes are NOT reported by Medicare?
Answer: D. S codes
Rationale: S codes are used by the Blue Cross Blue Shield Associate and the Health Insurance Association of America. They are also used by the Medicaid program but not payable by Medicare. In the beginning of the S codes the heading indicates Temporary National Codes Established by Private Payers (Non-Medicare) (S0000-S9999).
There are national HCPCS Level 11 codes representing more than 4000 separate categories of items, services…
To avoid any appearance of endorsement of a product … descriptors do NOT refer to specific products… brand names are not used.
RE: Permanent National Codes …
BCBSA (blue cross blue shield association) and
HIAA (Health Ins Assoc of America) and
CMS
maintain the national permanent HCPS Level 11 Codes.
They make additions, revisions deletions… they can NOT make unilateral decisions regarding permanent codes.
The revised Quarterly HCPCS updates can be found in the website.
https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/medhcpcsgeninfo/
Miscellaneous Codes …
NOC (not otherwise classified)
Claims w/ Misc. codes are manually reviewed.
*item/service must be clearly described
*pricing must be provided along w/ documentation.
Temporary National Codes
Allows insurers to establish codes needed before the next Jan 1 annual update.
or until consensus can be achieved.
Once Established, the codes are implemented within 90 days.
Temporary National Codes info. regarding implementation of codes can be found …
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.html.
Types of temporary HCPCS Codes
C codes
*id items that qualify for pass-through payments under HOPPS (Hospital Outpatient Prospective Payment System)
*these codes used on ACS and OPPS claims and are valid for Medicare claims by hospital outpatient dept.
ACS
Alliance Claim System
*allows providers to view claims, submit claims and treatment plans, check authorizations, and more.
G Codes
To id procedures and services for which there are no CPT codes.
H Codes
*Used by Medicaid to establish codes to id mental health services .. drug and alcohol treatment and no other code exists.
K Codes
*Tor Durable Medical Equipment Medicare Administrative Contractors (DME MAC) when no other code available.
Q Codes
*Id services that would NOT be given a CPT code.
*Include drugs, biologicals, other types of medical equipment etc which are NOT id’d by national level 11 codes.
S Codes
Used by BCBSA and HIAA to report drugs, services and supplies. There are NO other codes. May also be used by Medicaid, but NOT payable by Medicare.
T Codes
*Used by Medicaid to Id items with no permanent national codes.
*May also be used by private insurance companies to, but NOT payable by Medicare.
A Codes …
Transportation
*Ambulance
*Medical/Surgical
*Administrative
*Misc.
*Investigational
Billing Tip: on A codes
Read the code and description completely.
Bcuz some codes have specific quantities.
*per mile
*non-needle cannula type
*Per pair etc. etc.
B Codes: Enteral and Parenteral Therapy
Enteral (en-trr-uhl)
Parenteral (purr-en-trr-uhl)
Codes include
*formula used
*suuplies necessary to administer
Billing Tip
Take care to note the units of measure.
*100 calories per unit
*500 ml per unit or dependent on the grams of protein etc. etc.
C Codes:
Hospital OPPS
Outpatient Prospective Payment System
Codes describe outpatient setting.
*services
*drugs
*supplies
*biologicals
*radiopharmaceuticals
*radiology etc. etc.
Billing Tip on OPPS
C Codes are always billed on a UB-04
Exclusively used in the OP hospital setting for facility (technical) services.
D Codes Dental Procedures
Submitted on an ADA form
*Developed by ADA American Dental Association
*Terminology is referred to as CDT codes (Current Dental Terminology)
NOT included in the CPB certification exam.
E Codes: are for DME
Durable Medical Equipment
*canes
*crutches
*commodes
*decubitus care equipment
*bath and toilet
*hospital beds & accessories
*monitoring equipment
*wheelchair
DME is covered under Part B
Tip: Code must ensure that the code best describes the equipment to greatest level of specificity. GLOS
DME
*can withstand repeated use
*medical purpose
*NOT useful in absence of illnes, injury
*CAN be used at home
G Codes:
Procedures/Professional Services (Temporary)
G Codes under Medicare jurisdiction.
*Code not found in CPT book
*CPT code doesn’t exist or are NOT reimbursed by Medicare.
Example of G Code usage
*Medicare patient screening for cancer of colon HCPCS code used. G0104
*When patient is new to Medicare (within 12 months) on IPPE Initial Preventive Physical Exam G0402 instead of “preventive visit code above.”
Billing Tip:
For Medicare claims, the G codes take precedence over the CPT.
*Many of these codes have frequency limitations.
*Some require ABN Advanced Beneficiary Notice. Modifier GA should be reported w/ correct code when ABN signed.
H Codes:
Alcohol and Drug Abuse Services
A&DA
*Used by state Medicaid
*NOT billable to Medicare
*Mental health including A&DA
*At risk prenatal care
*Described as Physician or Non-Physician services, Short term, Long term.
J Codes:
Drug Administered Other Than Oral Method
Each HCPCS Level 11 book includes Table of Drugs
*Injectable
*Inhalation solution drugs
*Chemotherapy
*Immunosuppressive Drugs (usually self-administered)
J Codes
Dosage of medication can be listed as
*mg milligram
*ml milliliter
*mcg microgram
*will be listed w/ dosage per unit
Example:
J2270 Injection, morphine sulfate, up to 10mg
J Codes: It’s critical to read
*Description
*Dosing
*Method of administration
CMS Website
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2019ASPFiles.html.
K Codes
DME durable medical equipment
MACS Medicare Administrative Contractors Services
K Codes are temporary codes used by
DME MACs
*Primarily wheelchairs and accessories
*Accessories are leg rest, lower extension, replacement only etc.
L Codes: Orthotic * Prosthetic Procedures
Billing Tip:
Code should identify the correct anatomical area of prosthetic.
*Categorized by body area and subdivided for level of specificity
*Prosthetic devices (NOT dental) covered under Part B
M Codes for
Other Medical Services
*There are a limited number of codes in this section
EX: M0076 Prolotherapy
P Codes:
Pathology and Laboratory Services
Subdivided into four sections.
- Chemistry & Toxicology
- Pathology screening tests
- Microbiology
- Misc Pathology
Example P Code
P7001Culture, bacterial, urine; quantitative, sensitivity study
P9048Infusion, plasma protein fraction (human), 5%, 250 ml
Q Codes: Misc Services (Temporary)
*Supplies
*Procedures
*Services that include contrast material.
*PAP smears
*Chemotherapy
*Lab tests
*Pharmacy dispensing fees
R Codes
Diagnostic Radiology Services
*Transportation & Set Up of portable equipment
Example:
R0075 Transport equipment, more than one patient seen
Billing Tip
Claims will be denied if there is an office visit on the same day as the portable equipment is used. These services could be performed at the office during the visit.
S Codes: Temporary National Codes (Non-Medicare)
Tip:
S codes must NEVER be submitted to Medicare for payment.
*Developed by BCBSA and HIAA
*For services w/ no national codes
*Medicaid may use these codes
Rational: circumstances related to case rates, increase dose of meds, new surgical device, refined lab or fertility testing, specificity to mental health.
T Codes:
National Codes Established for State Medicaid Agencies
*Established by HIPAA
*SNF
*Substance abuse treatment
*Training related procedures
Example:
T1013Sign language or oral interpretive services, per 15 minutes
T5001Positioning seat for persons with special orthopedic needs
U Codes:
Coronavirus Diagnostic Panel
Example:
U0001 CDC 2019 novel coronavirus (2019-nCoV) real-time RT-PCR diagnostic panel
U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types of subtypes (includes all targets), non-CDC
V Codes:
Vision, Hearing, Speech-Language Pathology Services.
*Lens
*Contacts
*Vision aids
*Ocular prosthetics
*Speech language pathology
*Hearing services
Under Medicare jurisdiction and are for non-physician services only.
HCPCS
If a CPT and HCPCS exist for same service, make sure it’s for same procedure, and refer to payer policies for guidance.
Is at the discretion of the local MAC
Medicare Administrative Contractor
in CA it’s Noridian.
If CPT and HCPCS code descriptions are slightly different
Report the HCPCS code for patients who have Medicare according to the guidelines.
HCPCS Level 11 National Modifiers appended …
*Two numeric digits
*To specify special circumstances
Example:
*Mod 22 Unusual/Increased procedural
*Mod 52 Reduce/Eliminate services
*The physical status of pt. receiving anesthesia is reported using a modifier
*P1: normal healthy patient
*P2: w/ mild disease
*P3: Severe systemic disease
*P4: SSD that’s a threat to life
*P5: moribund NOT expected to survive
Level 11 Modifiers are two alpha
(AA-PP) followed by a digit.
They are subdivided into subsections for
*Anatomy
*Transportation
*Anesthesia
*Coronary Arteries
*Ophthalmology
*Professional services
*End-stage disease
*Dental care
Modifier
AI
Principal physician of record
Modifier
CC
When procedure code submitted was changed for admin reasons or incorrect code was filed
Modifier
E1
Upper left, eyelid
Modifier
E2
Lower left, eyelid
Modifier
E3
Upper right, eyelid
Modifier E4
Lower right, eyelid
Modifier E5
Right hand, thumb
Modifier F6
Right hand, second digit
Modifier F7
Right hand, third digit
Modifier F8
Right hand, fourth digit
Modifier F9
Right hand, fifth digit
All these two letter digit codes are Modifiers too.
GA
Waiver of liability
Appended when ABN signed.
GG
Screening mammogram and diagnostic mammogram same patient, same day.
GH
Diagnostic mammogram converted from screening on same day.
LC
Left circumflex coronary artery
LD
Left anterior descending coronary artery.
NR
New when rented DME durable medical equipment and then purchased.
NU
New equipment
Q6
fee-for-time service by substitute physician or physical therapist in a staff shortage area, medically underserved area, rural area.
QS
Monitored anesthesia care services.
RC
Right coronary artery
RR
Rental DME durable medical equipment.
Ambulance Origin and Destination Modifiers:
*Single character combined
*1st Denotes origin of ambulance service
*2nd character is for destination
Example:
HH:
Ambulance trip from discharge/transfer from one hospital to another hospital
RH:
Ambulance trip from the patient’s residence to a hospital
SH:
Ambulance trip from scene of accident to a hospital
RP:
Ambulance trip from the patient’s residence to a physician’s office
D: other than Hospital or Physician’s
E: Residential, Custodial (NOT 1819 facility)
G: Hospital based dialysis facility
H: Hospital
I: Site of transfer (airport, helicopter)
N: SNF
P: Physician’s Office
R: Residence
S: Scene of accident or acute event
X: Intermediate stop at physician’s
TC
Technical component
Reporting for Discarded Drugs/ Meds
Claim reported w/ one item line indicating amount of drug used.
Second line item to report amount of drug discarded w/ Modifier JW.
*Single-use vials contain more medication than administered to pt.
*According to MCPM Medicare Claims Processing Manual, Provider may bill for remaining portion discarded using Modifier JW.
*Does NOT apply to drugs, biologicals under CAP Competitive Acquisition Program for Part B drugs and biologics or when multi-dose vial is used.
Example:
100 units of Botox must be used within 4 hours. Only 90 units administered to 3 patients. 10 units are waste.
Patient 1: J0585 x 30
Patient 2: J0585 x 30
Patient 3: J0585 x 30 J0585-JW x 10
Billing Tip
JW is not to be used with discarded amounts from a multi-dose vial (MDV) or when the remaining amount is used on another patient instead of discarded.
Review 6.2 Page 78
What HCPCS Level II code and unit(s) is reported for 4 boxes of alcohol wipes?
A: A4245x4
Rationale: Look in the HCPCS Level II Index for Alcohol wipes. It directs you to A4245. HCPCS code A4245 is reported per box, so you will need to report 4 units for the 4 boxes of alcohol wipes.
Review Page 78
Patient is given 15 mg of methotrexate sodium IM for rheumatoid arthritis given from 5 mg vials. What HCPCS Level II code and unit(s) is reported?
Answer: D. J9250 x 3
Rationale: Look in the HCPCS Level II Table of Drugs for Methotrexate Sodium, one of the routes is IM (intramuscular) directing you to code J9250. This drug is reported for 5 mg. The patient received 15 mg of methotrexate. The correct way to code this injection is J9250 x 3 (3 x 5 = 15 mg).
Select the supply code for an insertion tray that has a two way all silicone Foley catheter with a drainage bag?
Answer: C. A4315
Rationale: Look in the HCPCS Level II Index for Foley catheter. This directs you to codes A4312-A4316, A4338-A4346. Review the codes, code A4315 is the correct code because the two-way Foley catheter was all silicone with a drainage bag.
An audiologist provides a battery for a hearing device to a patient. What HCPCS Level II code is reported for the battery?
Answer: D. V5266
Rationale: Look in the HCPCS Level II index for Battery/Hearing device and you are directed to V5266. Review the codes and code V5266 is the correct code to report.
A female patient is getting a right and left breast mastectomy bra with integrated form breast prosthesis. What HCPCS Level II code is reported?
Answer: A. L8002
Rationale: Look in the HCPCS Level II index for Breast/Prosthesis/Mastectomy bra/With integrated form, bilateral which directs you to L8002. Modifier 50 is not reported on the code because the code description already indicates that the bra is for a bilateral integrated prosthesis.
Abbreviations
g grams
IM Intramuscular
IV Intravenous
mcg micrograms
mg milligrams
ml milliliters
SQ subcutaneous
Enteral Nutrition
For impaired ability to chew/swallow or ingest food
ABN
Medicare may deny service payment.
HCPCS Level 11
National procedure code set
Injection
Fluid introduced into tissue, cavity, vessel usually by needle
Locum Tenes
Modifier Q6
Substitute physician for reasons such as illness, pregnancy, vacation, continuing medical education.
Parenteral nutrition
Nutrients delivered IV for Post-Op, in shock, unresponsive.
Subcutaneous
SQ
