1. Chapter 7: HCPCS Level II National Coding System
Unit 5 Presentation
Chapter 7: HCPCS Level II National Coding System

2. Overview
Three levels
HCPCS level I
HCPCS level II
HCPCS level III 2

3. HCPCS Level I Five-digit CPT codes and two-digit modifiers
Developed by American Medical Association (AMA)
Updated annually-Jan. 1 3

4. 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)
Identify services by physician and non physician providers (NP, Pas, therapists), ambulance services, and DME 4

5. Durable Medical Equipment (DME)
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
Defined by Medicare as equipment that:
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
DMEPOS-durable medical equipment, prosthetics, orthotics and supplies dealers-supply patient with DME
Canes
Crutches
Wheelchairs
Walkers
Commode chairs
Glucose monitors 5

6. HCPCS Level III
Effective December 31, 2003, HCPCS level III local codes are no longer reported. 6

7. HCPCS Level II National Codes
Classify similar medical products and services for claims processing
Each code contains a description:
DME
Medications
Provider services
Temporary Medicare codes (e.g., Q codes)
Other items and services (e.g., ambulance) 7

8. HCPCS Level II National Codes
HCPCS National Panel responsible
Panel consists of:
Blue Cross/Blue Shield Association
Health Insurance Association of America
CMS
HCPCs maintained by the national panel:
Blue Cross/Blue Shield Association
Health Insurance Association of America
CMS 8

9. Common HCPCS Level II References
General guidelines and instructions
Appendix (e.g., additions, deletions)
Table of drugs or deleted codes
Symbols
Special coverage instructions
Current national modifiers
Reverences for HCPCS Level II codes include:
General guidelines and instructions
Appendix (e.g., additions, deletions)
Table of drugs or deleted codes
Symbols
Special coverage instructions
Current national modifiers 9

10. HCPCS Level II Organized by type Permanent national codes Dental codes
Miscellaneous codes
Temporary codes
Modifiers
Permanent national codes-maintained by HCPCs National Panel
Dental codes-include dental procedures and supplies, maintained by American Dental Association
Miscellaneous codes-codes that are reported when a DMEPOS dealer submits a claim for a product that has no HCPCs Level II Code
Temporary codes-
maintained by CMS and other member of HCPCs panel,
updated more than once a year,
can be replaced by a permanent code
Modifiers-Attach to CPT (level I) or HCPCS (level II) codes 10

11. HCPCS Level II Modifiers
Attached to any HCPCS level I or II code
Provide additional information
Not all codes require modifiers 11

12. HCPCS Level II Index Entries
Permission to reuse in accordance with Web site Content Reuse Policy. 12

13. HCPCS Level II Medical and Surgical Supplies (A4000-A8999)
Administrative, Miscellaneous and Investigational (A9000-A999)
Enteral and Parenteral Therapy (B4000-B9999)
Dental procedures (D0000-D9999)
Supplies, devices (hip replacement, pacemaker), drugs 13

14. HCPCS Level II DME (E0100-E999)
Procedures/Professional Services (Temporary) (G0000–G9999)
Alcohol and/or Drug Abuse Treatment Services (H0001–H2037)
Drugs Administered other than Oral Method (J0000–J9999)
(continued) 14

15. HCPCS Level II Temporary codes (K0000-K9999)
Orthotic Procedures (L0000–L4999)
Prosthetic Procedures (L5000–L9999)
Medical Services (M0000–M0301)
Pathology and Laboratory Services (P0000–P9999) 15

16. HCPCS Level II J Codes
Permission to reuse in accordance with Web site Content Reuse Policy. 16

17. HCPCS Level II Q codes (temporary) (Q0000–Q9999)
Diagnostic radiology services (R0000–R5999)
Temporary national codes (non-Medicare)(S0000-S9999)
National T codes established for state Medicaid agencies (T1000–T9999)
Vision services (V0000-V2999)
Hearing services (V5000-V5999) 17

18. Determining Payer Responsibility
Specific code determines where claim is sent
Medicare administrative contractor (MAC)
DME Medicare administrative contractor (MAC)
Annual list of billing codes and billing instructions
MAC-government agency that process medical claims
DME MAC- process DME claims
Providers and DMEPOS dealers obtain an annual list of valid national codes that include the billing instructions for services. 18

19. Patient Record Documentation
Justifies medical necessity of procedures, services, and supplies coded and reported
Documentation should include:
Patient history, including review of systems (ROS)
Physical examination
Diagnostic test results
Diagnoses (duration and comorbidity)
Prognosis 19

20. 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 20

21. DMEPOS Claims Certificate of medical necessity
Prescription for DME, services, and supplies
DME MAC medical review policies
Include local and national coverage determinations
For certain claims DMEPOS must get a Certificate of medical necessity
Must be kept on file
DME MAC medical review policies
They define the coverage criteria, payment rules, and documentation requirements for DME equipment
Must fall within a benefit category
Not be excluded by statute or by national CMS policy
Be reasonable and necessary to diagnose and/or treat an illness or injury or to improve the functioning of a malformed body. 21

22. Introduction to CPT Coding
Chapter 8
Introduction to CPT Coding

23. History of CPT 1966 1970 1983 1986 1996 2004 Published by AMA
Five-digit codes
1983
Adopted as part of HCPCS
1986
Omnibus Budget Reconciliation Act (OBRA)
1996
HIPAA
2004
MMA
(continued) 23

24. CPT Mandated Reporting
Home health care and hospice agencies
Outpatient hospital departments
Physicians who are employees of a health care facility
Physicians who see patients in their offices or clinics and in patients’ homes
These facilities are mandated to use CPT 24

25. Nonreportable Services
Considered integral to procedure
No separate code reported
For example:
Administering sedatives
Cleansing, shaving, and prepping of skin
Draping and positioning of patient
Irrigating a wound
Inserting and removing drains 25

26. CPT-5 Fifth edition Codes remain five digits in length
Changes include:
Support of electronic data interchange (EDI), computer-based patient record (CPR), or electronic medical records (EMR)
Tracking of new technology and performance measures
Glossary
Electronic index (under development) 26

27. CPT Categories Category I codes Category II codes Category III codes
Procedures and services
Category II codes
Performance measures
Category III codes
Emerging technology 27

28. Organization of CPT Six sections:
Evaluation and Management (E/M) (99201–99499)
Anesthesia (00100–01999, 99100–99140)
Surgery (10021–69990)
Radiology (70010–79999)
Pathology and Laboratory (80048–89356)
Medicine (90281–99199, 99500–99602) 28

29. CPT Index Alphabetic main terms Boldfaced
Represent procedures or services, organs, anatomic sites, conditions, eponyms, or abbreviations
Subterms indented below 29

30. Selection from CPT Index
Current Procedural Terminology © 2008 American Medical Association. All rights reserved. 30

31. CPT Index Organization Procedures or services (e.g., endoscopy)
Organs or other anatomic sites (e.g., elbow)
Conditions (e.g., wound)
Synonyms (e.g., finger joint or intercarpal joint)
Eponyms (e.g., Whitman procedure)
Abbreviations (e.g., MRI)
(continued) 31

32. CPT Index Boldfaced type Italicized type
Main terms, categories, subcategories, and code numbers
Italicized type
Cross-reference terms (e.g., see)
Directs coders to index entry under which codes are listed 32

33. Appendices Appendix A Appendix B Appendix C
List of modifiers and descriptions
Appendix B
Annual CPT coding changes
Appendix C
Clinical examples for codes found in E/M section
(continued) 33

34. Appendices Appendix D Appendix E Appendix F List of add-on codes
Identified with plus symbol (+)
Appendix E
List of codes that are exempt from modifier -51
Appendix F
List of codes that are exempt from modifier -63
(continued) 34

35. Appendices Appendix G Appendix H
Summary of CPT codes identified with bull’s eye symbol ()
Codes that include Moderate (Conscious) Sedation (MCS)
Appendix H
Alphabetic index of performance measures by clinical condition or topic
(continued) 35

36. Appendices Appendix I Appendix J Appendix K Genetic testing modifiers
Electrodiagnostic medicine listing of sensory, motor, and mixed nerves
Appendix K
List of codes pending FDA approval
(continued) 36

37. Appendices Appendix L Appendix M List of vascular families
List of deleted CPT codes and descriptions with crosswalk to new CPT codes 37

38. CPT Symbols
Bullet located to the left of code identifies new procedures and services (●)
Triangle located to the left of code identifies revision of code description (▲)
Horizontal triangles surround revised guidelines and notes (►◄)
There are eight symbols within the CPT book 38

39. CPT Symbols Semicolon saves space in CPT (;)
Plus identifies add-on codes for procedures that are commonly, but not always, performed at the same time and by the same surgeon as the primary procedure (+) 39

40. CPT Symbols
Circle with slash identifies forbidden or prohibited codes exempt from modifier -51 ()
Bull’s eye identifies a procedure that includes MCS ()
Flash identifies codes that classify products pending FDA approval ()
(continued) 40

41. CPT Symbols Symbol CPT Entry Use of semicolon 11000
Current Procedural Terminology © 2008 American Medical Association. All rights reserved.
Symbol
CPT Entry
Use of semicolon
11000
Debridement of extensive eczematous or infected skin; up to 10% of body surface
Use of plus symbol
Each additional 10% of body surface (List separately in addition to code for primary procedure)
Use of -51 modifier exemption symbol
 17004
Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions
Use of bull’s eye symbol
 33206
Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial 41

42. CPT Guidelines
Define terms and explain assignment of codes for procedure and services
Located at beginning of each CPT section
Guidelines from one CPT section do not apply to another CPT section
Should be reviewed before assigning code

43. Sections, Subsections, Categories, and Subcategories
Six sections are subdivided into:
Subsections
Categories
Subcategories
Guidelines at beginning of each subsection
Notes, parenthetical notes, and descriptive qualifiers are in each of the Sections, Subsections, Categories, and Subcategories 43

44. Sections, Subsections, Categories, and Subcategories
Selection from CPT that illustrates sections, subsections, categories, subcategories, notes, and descriptive qualifiers
Current Procedural Terminology © 2008 American Medical Association. All rights reserved. 44

45. Unlisted Procedures and Services
Unlisted procedure or unlisted service
Assigned when provider performs procedure or service for which there is no CPT code
Special report must accompany claim to provide more information (e.g., copy of procedure report) 45

46. Instructional Notes Blocked un-indented note
Indented parenthetical note
Parenthetical note
Blocked un-indented note-
Located below the title of a subsection, heading or subheading
contains instructions that apply to all codes in the subsection/heading/category/subheading/subcategory
Indented parenthetical note-
Located below the title of a subsection, heading, and subheading
Note applies to only that code unless specified otherwise
Parenthetical note
Located in the code description to provide examples 46

47. Descriptive Qualifiers
Terms that clarify assignment of CPT code
They can occur in the middle of a main clause or after a semicolon and may or may not be enclosed in a parentheses.
Make sure you read all descriptions carefully before assigning a code! 47

48. Modifiers Clarify services and procedures performed by providers
Reported as two-digit numeric codes added to five-digit CPT code
HCPCS level II national two-digit alpha-numeric modifiers also are added to five-digit CPT code
(continued) 48

49. Special E/M Cases -21 Prolonged E/M services
-24 Unrelated E/M service by same physician during postoperative period
-25 Significant, separately identifiable E/M service by same physician on same day of procedure or other service
-57 Decision for surgery 49

50. Greater, Reduced, or Discontinued Services
-22 Increased procedural services
-52 Reduced services
-53 Discontinued procedure
-73 Discontinued outpatient hospital/ ambulatory surgery center procedure prior to anesthesia
(continued) 50

51. Greater, Reduced, or Discontinued Services
-74 Discontinued outpatient hospital/ ambulatory surgery center procedure after anesthesia administration 51

52. Global Surgery -54 Surgical care only
-55 Postoperative management only
-56 Preoperative management only 52

53. Special Surgical and Procedural Events
-58 Staged or related procedure or service by same physician
-59 Distinct procedural service
-63 Procedure performed on infants less than 4 kilograms (kg)
(continued) 53

54. Special Surgical and Procedural Events
-78 Return to operating room for related procedure during postoperative period
-79 Unrelated procedure or service by same physician during postoperative period 54

55. Bilateral and Multiple Procedures
-50 Bilateral procedure
-27 Multiple outpatient hospital E/M encounters on same date
-51 Multiple procedures 55

56. Repeat Services -76 Repeat procedure by same physician
-77 Repeat procedure by another physician 56

57. Multiple Surgeons -62 Two surgeons -66 Surgical team
-80 Assistant surgeon
-81 Minimum assistant surgeon
-82 Assistant surgeon (when qualified resident not available) 57

58. Professional and Technical Components
-26 Professional component
TC Technical component (found in HCPCS level II manual) 58

59. Mandated Services -32 Mandated services -23 Unusual anesthesia
-47 Anesthesia by surgeon 59

60. Laboratory Services -90 Reference (outside) laboratory
-91 Repeat clinical diagnostic laboratory test
-92 Alternative laboratory platform testing 60

61. Multiple Modifiers -99 Multiple modifiers
Used to alert third party payer that there are more than four modifiers on the CPT 61

62. NCCI Promotes national correct coding methodologies
Controls improper code assignment
Implemented by CMS
Edits used to process Medicare Part B claims
Medicare part B are outpatient claims 62

63. NCCI Edits Two types: Comprehensive/Component edits
Mutually exclusive edits
Comprehensive/Component edits-code pairs that should not be billed together because one service inherently includes the other
Mutually exclusive edits-code pairs that , for clinical reasons, are unlikely to be performed on the same patient on the same day,
Example two different types of test that yield equivalent results. 63

64. Advanced Beneficiary Notice (ABN)
Form completed and signed by Medicare beneficiary each time provider believes a normally covered service will not be covered and provider wants to bill beneficiary directly for the service 64

65. Notice of Exclusions from Medicare Benefits (NEMB)
Form completed and signed by Medicare beneficiary before items, procedures, and services excluded from Medicare benefits are provided 65

66. Unbundling
Reporting multiple codes for a service when a single, comprehensive code should be assigned 66

67. Questions