Health Information Management

Note similarities and differences between HCPCS, CPT® codes

JustCoding News: Outpatient, September 5, 2012

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

by Lori-Lynne A. Webb, CPC, COBGC, CCS-P, CCP, CHDA

As a medical coder, you are sometimes presented with code sets that embody similar codes. Such is the case with some of the codes within CPT® and HCPCS. Both the seasoned and inexperienced coder may struggle to determine which code or code set to use. So how do coders, determine the best code choice for the procedure performed?
 
HCPCS background information
The HCPCS code set is based on the AMA’s CPT processes. HCPCS was established in 1978 to provide a standardized coding system for describing specific items and services. Initially, facilities voluntarily used HCPCS codes, but with the implementation of HIPAA in 1996, facilities began to report HCPCS for transaction codes. HCPCS has its own coding guidelines and works hand in hand with CPT. HCPCS includes three separate levels of codes:
  • Level I codes consist of the AMA’s CPT codes and is numeric.
  • Level II codes are the HCPCS alphanumeric code set and primarily include non-physician products, supplies, and procedures not included in CPT.
  • Level III codes, also called HCPCS local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. These are still included in the HCPCS reference coding book. Some payers prefer that coders report the Level III codes in addition to the Level I and Level II code sets. However, these codes are not nationally recognized.
 
As with CPT, the HCPCS Level II codes standardize similar products and categories for processing the medical claim. The HCPCS codes are primarily used for billing and identifying items and services. These items and services primarily include non-physician based services such as:
  • Ambulance services
  • Prosthetic devices
  • Drugs, infusion additives, and ancillary surgical supplies
  • Non-physician services not covered by CPT codes (Level I codes)
Divisions within HCPCS
Coders will find the following sections in the HCPCS Manual:
  • A codes, transportation, medical and surgical supplies, miscellaneous and experimental
  • B codes, enteral and parenteral therapy
  • C codes, temporary hospital OPPS
  •  E codes, durable medical equipment
  • G codes, temporary procedures and professional services
  • H codes, behavioral health/substance abuse services
  • J codes, drugs administered other than oral method, chemotherapy drugs
  • K codes, temporary codes for durable medical equipment regional carriers
  • L codes, orthotic/prosthetic procedures
  • M codes, other medical services
  • P codes, pathology and laboratory
  • Q codes, temporary codes (limited use and guidelines specific)
  • R codes, diagnostic radiology services
  • S codes, temporary national codes (non-Medicare) codes
  • T codes, temporary state Medicaid agency codes
  • V codes, vision/hearing services
 
Dental (D) codes, which make up a separate category of national codes, are a part of the Current Dental Terminology (CDT®) code set. The American Dental Association (ADA) now publishes this dental code set in a copyrighted publication that lists codes for billing for dental procedures and supplies. While the CDT codes are considered HCPCS level II codes, the ADA, not the CMS HCPCS Workgroup, makes decisions regarding the revision, deletion, or addition of CDT codes. As of January 2011, the CDT codes are published by the ADA and not by CMS. Also, effective January 1, 2011, the dental codes were removed from the standard HCPCS book, and are now located in the CDT manual.
HCPCS and HIPAA
Under HIPAA, the HCPCS code sets are intended to be a uniform, fairly universal form of classifying similar durable medical equipment, prosthetics, and orthotics (DMEPOS). In addition, the HCPCS codes are to be used by all entities included in the definition of a health plans. CMS defines health plans as the following:
  • A group health plan, health insurance issuer or HMO, as defined in that section
  • Part A or Part B of the Medicare program
  • The Medicaid program
  • An issuer of a Medicare supplemental policy
  • An issuer of a long-term care policy, excluding a nursing home fixed-indemnity policy
  • An employee welfare benefit plan or any other arrangement that is established or maintained for the purpose of offering or providing health benefits to the employees of two or more employers
  • The health care program for active military personnel
  • The Veterans health care program
  • The Civilian Health and Medical Program of the Uniformed Services
  • The Indian Health Service program
  • The Federal Employees Health Benefits Program
  • An approved state child health plan
  •  The Medicare+Choice program
  • A high-risk pool that is a mechanism established under state law to provide health insurance coverage or comparable coverage to eligible individuals
  • Any other individual or group plan, or combination of individual or group plans, that provides or pays for the cost of medical care
 
Determining which codes to use
As you can see, many, many types of health plans exist, so coders must ascertain whether to use the CPT or the HCPCS codes. Here’s a quick way to determine if you should use a HCPCS code or a CPT code:
  • When both a CPT and a HCPCS Level II code have virtually identical narratives for a procedure or service, use the CPT code. If, however, the narratives are not identical, use the HCPCS Level II code.
  • Check for a HCPCS national code when a CPT code description contains an instruction to include additional information, such as describing a specific medication.
Many HCPCS Level II codes specify supplies in greater detail than what coders will find in CPT. The HCPCS “J” codes include the majority of those drugs and biologicals that should be reported with infusions, injections, and supply codes that go hand in hand with CPT procedure based coding.
 
CMS can add, change, or delete the HCPCS temporary each quarter, however, the permanent HCPCS codes are updated annually and take effect January 1 of each year. Within the HCPCS temporary code set, these temporary codes are usually implemented within 90 days. There are many different types of temporary HCPCS codes found in the HCPCS Level II manual.
 
Types of temporary HCPCS codes
The G codes are used to identify professional health care procedures and services that would otherwise be coded in CPT but for which there are no CPT codes. Good examples of these codes include the following:
 
  •  G0101, cervical or vaginal cancer screening; pelvic and clinical breast examination
  • G0105, colorectal cancer screening; colonoscopy on individual at high risk
  • G0108, diabetes outpatient self-management training services, individual, per 30 minutes
Certain H codes are used by state Medicaid agencies that are required to establish separate codes for identifying mental health services, such as alcohol and drug treatment services. H codes include:
  • H0001, alcohol and/or drug assessment
  • H0049, alcohol and/or drug screening
  • H1000, prenatal care, at-risk assessment
The K codes were established for use by the durable medical equipment (DME) Medicare Administrative Contractor (MAC) when the current existing permanent national codes do not include the codes needed to implement a DME MAC medical review policy. These codes include:
  • K0012, lightweight portable motorized/power wheelchair
  • K0455, infusion pump used for uninterrupted parenteral administration of medication, (e.g., epoprostenol or treprostinol)
  • K0105, IV hanger, each
The Q codes are used to identify services that would not be given a CPT code, such as drugs, biologicals, and other types of medical equipment or services, and which are not identified by national Level II codes. However, these services and equipment need codes for claims processing purposes. A good example of these codes includes:
  • Q0035, Cardiokymography
  • Q0114, Fern test
  • Q0144, Azithromycin dihydrate, oral, capsules/powder, 1 gram
Coders use the S codes to report drugs, services, and supplies without national codes to private insurers (non-Medicare/Medicaid/Federal programs). Examples of the S codes include:
  •  S0516, safety eyeglass frames
  • S2900, surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)
  •  S9436, childbirth preparation/lamaze classes, non-physician provider, per session
 
State Medicaid agencies use T codes for items without permanent national codes, but meet a national Medicaid program operating need. T codes are not used by Medicare but private insurers can use them. They include:
  • T1013, sign language or oral interpretive services, per 15 minutes
  •  T1005, respite care services, up to 15 minutes
  • T1014, telehealth transmission, per minute, professional services bill separately
 
The HCPCS A, B, J, L, and M codes follow their own guidelines. Carefully review these guidelines, which are contained in your HCPCS manual.
 
Those guidelines set forth by CMS will also help you make the correct determination whether to use a HCPCS code or the traditional CPT code. If you don’t know whether to report a HCPCS or CPT code for a particular third-party payer, don’t be afraid to give the payer a call and ask what they would like to see on the claim. Many private third-party payers have strict rules as to the submission of a HCPCS code.
 
HCPCS Manual appendices
Coder should also know what is contained in the entire HPCS code manual. The HCPCS Level  II Manual includes the alphabetic and alphanumeric code set, but also includes appendices, similar to CPT. The HCPCS appendices may include:
 
  • Table of Drugs and Biologicals
  •  Deleted codes
  • Place of service codes
  • Type of service codes
  • Berrenson-Eggers type of service codes
  • Modifiers
 
As you become more familiar with the HPCS codes and processes, you will be able to discern morereadily which code set to use: CPT or HCPCS.
 
Editor’s note: Webb is a coder at St. Alphonsus Regional Medical Center in Boise, Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer and AHIMA ACE mentor. Email her at LORIWEBB@sarmc.org or webbservices.lori@gmail.com.

 



Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Most Popular