The Healthcare Common Procedure Coding System (HCPCS) is a standardized coding system used to describe products, supplies, procedures and services provided in the delivery of healthcare in the United States.
Products
Purpose and Use
The main purpose of HCPCS is to provide a standardized system for healthcare providers, healthcare facilities and insurers to report and track various
procedures,
services,
products
and supplies.
It allows for efficient processing of healthcare claims by insurance providers.
HCPCS codes are used for claim submission to Medicare, Medicaid, and private healthcare insurers when billing for procedures, services, products or supplies.
HCPCS has three levels of codes:
Level I – Consists of Current Procedural Terminology (CPT) codes which are numeric codes maintained by the American Medical Association (AMA) to describe medical procedures and physician services.
CPT codes make up the bulk of HCPCS codes used for billing and reimbursement.
Level II – Contains alphanumeric codes that identify healthcare products, supplies and services not included in the CPT codes
such as ambulance services, prosthetics, orthotics, medical supplies and durable medical equipment. Level II HCPCS codes are maintained by CMS.
CPT
Structure :- numeric ( five character)
Category 1: codes represent procedure service widely (surgery ,medical evaluation diagnostic test )
Category 2 : optional codes used performance measurement and quality reporting
Category 3 : temporary codes ( emerging technology . services procedure )
0099T= wireless pulmonary artery pressure sensor
Level III –
- Made up of local codes used by state Medicaid agencies, Medicare contractors and private insurers for procedures, services, and supplies not described by CPT or Level II HCPCS codes. Level III codes are not standardized.
- customization based on unique requirements each state program
- HCPCS codes provide a standard method for describing services and procedures. They provide specifics about the procedure, service or supply being billed for. This allows insurers to understand what is being billed and determine appropriate reimbursement.
HCPCS Coding Conventions
- HCPCS codes follow certain conventions in terms of format and structure:
Codes are either 5 numeric digits for CPT codes or 5 alphanumeric characters for Level II and III HCPCS codes - Codes are structured based on broad categories. For example CPT codes in the 10000-19999 range relate to surgery, while HCPCS Level II codes in the E0000 range are reserved for durable medical equipment
HCPCS Coding Conventions
In the alphanumeric Level II codes, the single letter in the middle indicates the type of item – for example E codes represent durable medical equipment, J codes are drugs administered by a provider
The 4th and 5th digits in Level II HCPCS codes provide additional specificity to define the product or service
- Examples
- 99204 = office any outpatient visit = history , exam medical decision ( more comprehensive New patient ,
- 99213 = office any outpatient visit = evaluation , management established patient
- 29881 = Arthroscopy , knee surgical with menisectomy ( medial , lter shaving mensical )
- 43235 = esophagogastroduodenoscopy , flexible . transoral . biopsy single multiple .
78452 = SPECT
93000 = ECG 12 Leads .with report
Level 2
Durable Medical equipment
E0140 = Height ( walker rigid wheeled adjustable
E0431= Liquid oxygen system ( portable)
Medical supplies
A4230 = Infusion set ( external insulin pump . non needle cannula type
A4556 = Non elastic binder for extremity
A0428 = Ambulance service , basic life support , non emergency transport , one way
A0431 = Ambulance service , basic life support , emergency transport(ALS1)S0012 = Ambulance , conventional air services , level 1(per mile )
T1001 = personal care services , 15 minutes , not for inpatient or resident inside hospital , nursing facilty ICF/DD residental care apartment complex
C1777 sten non coated.non covered delivery
G6024 anterior segment aqueous drawing drive
HCPCS Modifiers
In addition to the 5-character HCPCS codes, modifiers may also be appended to the end of the code. Modifiers provide additional information to insurers about the procedure, service or supply coded. Some examples of HCPCS modifiers include:
- 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
- LT or RT – Left/Right Side – used to identify procedures performed on the left or right side of the body
- 26 – Professional Component – used to identify the provider component of a service or procedure when billing separately from a facility component
HCPCS Version Indicator
HCPCS codes versions are updated annually and are identified by a version indicator in the code. Valid version indicators are:
- No indicator – valid for use
- D = deleted code – no longer valid for use
- M = modified description – code still valid but description changed
- By including version indicators, users know whether codes are still valid and can update billing systems accordingly.
Administration and Governance
- CMS has authority over all HCPCS code sets. CPT codes (Level I) are developed and maintained by the AMA via the CPT Editorial Board.
- The CMS HCPCS Workgroup oversees additions, deletions and edits to Level II HCPCS codes. This workgroup consists of representatives from CMS, state Medicaid agencies, the Blue Cross Blue Shield Association and other major healthcare insurers.
- The HCPCS system requires ongoing updates to incorporate new technologies, procedures, services and supplies. Extensive processes are in place to review code change requests and obtain expert opinions to evaluate proposals. This allows HCPCS to remain up-to-date to effectively support medical billing and reimbursement in our evolving healthcare system.
